Delay in referral nearly proved fatal

A patient saw her GP complaining of pain in her left loin and suprapubic pain. She had a history of nausea and urinary frequency. A presumptive diagnosis of pyelonephritis was made and a urine sample sent to the lab. The patient was started on antibiotics.

The following day the patient had a telephone consultation with another GP in the practice, saying there was no improvement in her symptoms. The GP changed the antibiotics.

Three days later the patient saw the second GP and reported continued pain in the left loin. The GP performed an examination, but no abnormalities were detected. The patient's mid-stream urine was negative and a diagnosis of urinary tract infection made. The patient was advised to finish the course of antibiotics, and if there was no improvement she would be referred for an ultrasound scan.

A month later the patient was seen by the second GP again as her condition had not improved. A further urine sample was sent to the lab and a different antibiotic started, with analgesia.

The patient was next seen by the out-of-hours service with a two-week history of abdominal pain. No dysuria or frequency was noted. The patient was apyrexial, and her vital signs normal. On examination, there was no evidence of abdominal tenderness. The urine sample revealed blood protein and white cells and a presumptive diagnosis of possible renal colic/urinary tract infection was made. The patient was advised to continue the antibiotics and to see her GP in the morning for further investigation.
 
She was seen that morning by the first GP and was referred for an x-ray of her kidneys and an intravenous pyelogram. Her condition deteriorated later that day and she was advised to go to hospital where she was found to have abdominal tenderness, especially in the suprapubic area and right iliac fossa.
 
A CT scan showed bilateral tubo-ovarian abscesses associated with pelvic inflammatory disease. The patient was very unwell and was taken to theatre where peritonitis was found and a bilateral salpingo oophorectomy was performed. The patient did not recover quickly and had post-operative complications.

Both GPs received a letter of claim from the patient's solicitors alleging that the delay in referring the patient to hospital had proved nearly fatal, that the patient had suffered permanent injury in that she was unable to have children, and that she was suffering from psychological problems.

The MDU's response

The MDU consulted a GP expert who agreed that the 'watch and review' approach taken by the GP initially was reasonable as the claimant's condition was not worsening. However, at the patient's final GP consultation before being admitted to hospital, the expert was concerned that there was no documented clinical examination and no urgent investigation. The expert felt the latter should have been instituted at this stage although he noted that the GP had advised the patient to go to hospital later on the same day, which was appropriate.

The MDU received an opinion from a gynaecological expert who was asked whether the delay had made any difference to the eventual outcome for the patient. He advised that he did not think a gynaecologist seeing the patient between her initial consultation and the time when she was seen by the out-ofhours service would necessarily have made a diagnosis of pelvic inflammatory disease.

He also pointed out that the doctors had prescribed antibiotics which are commonly used when treating pelvic inflammatory disease and therefore it was his opinion that the natural history of this infection would not have been altered had the patient been referred earlier.

The MDU wrote to the claimant's solicitors to point out that they had incorrectly interpreted the medical record and that the chronology in their letter of claim was inaccurate. Nearly a year later, the claim was discontinued.

Learning points

  • If a potential diagnosis is considered, appropriate steps should be taken to exclude that diagnosis within a reasonable timescale.
  • The management and follow-up plan should be formulated from an appropriate history and examination and documented in the records.
  • Ensure you make appropriate, timely referrals for further assessment, treatment or procedures, particularly if there is no improvement in the patient's condition.

This page was correct at publication on 15/12/2010. Any guidance is intended as general guidance for members only. If you are a member and need specific advice relating to your own circumstances, please contact one of our advisers.