Delayed diagnosis of infective endocarditis

Medical History

 

A patient in his late fifties was diagnosed by his then GP (member of another defence organisation) as having an apical systolic murmur and referred to a cardiologist. He confirmed that the patient had a minor degree of mitral valve prolapse but with no serious degree of regurgitation. The cardiologist informed the patient's GP of the diagnosis and advised that the patient should receive antibiotic prophylaxis for any future invasive procedures, including dental scaling.

Two years later the patient attended his dentist (member of another defence organisation) for a routine appointment, which included scaling. No antibiotic prophylaxis was given.

Two months later the patient presented to his current GP (member of the MDU), complaining of poor sleep and work stress. The GP took the patient's blood pressure, prescribed amitriptyline and asked the patient to come back in a month's time. Three days later another GP in the practice (member of another defence organisation) visited the patient at home for what was considered to be an upper respiratory tract infection. Over the next ten days the patient's usual GP saw the patient three times. On the last occasion, the patient told him that he had not been able to return to work because of backache, and that he had a poor appetite. The GP arranged for blood tests and asked the patient to return in a week's time for the results. These revealed a haemoglobin of 12.2g/dl, white cell count (WCC) 13.1x109/litre and an erythrocyte sedimentation rate (ESR) of 80mm. The pathologist had commented: '...anisocytosis and occasional lymphocyte seen. Occasional 'blast cells' seen suggest repeat in a week's time with heterophile antibody...'. The GP advised the patient to attend for more tests as suggested.

The results of the second batch of tests were available when the patient saw his GP three weeks later. The GP noted that the ESR was now 66 (from 80), while the WCC had dropped from 13.1 to 9.9. He wondered whether the patient had a viral infection. The patient again saw the GP two weeks later, when he noted that the patient looked pale but felt better. His weight had gone down. At examination the patient's stomach was found to be soft. The patient also had a sore throat and the GP prescribed an antibiotic. He decided to repeat the blood tests and these were telephoned to him the next day. This time the haemoglobin was 9.7, WCC 11.1 and the ESR 29. The GP, who suspected a gastro-intestinal malignancy, arranged an appointment with a consultant physician for the following day.

At examination the consultant found that the patient had a tachycardia, loud apical systolic murmur and splinter haemorrhages under his finger and toe nails. He suggested that the patient should be admitted for further tests but the patient deferred this for five days until after his wife's birthday. Subsequent investigations confirmed a diagnosis of infective endocarditis due to streptococcus sanguinis (a mouth commensal). The patient was treated with antibiotics and discharged six weeks' later having made a good recovery.

The patient remained well for nine months but then presented to his GP with evidence of mild congestive heart failure. He was immediately referred to the consultant physician who treated him with diuretics and digoxin. He was, however, admitted to hospital five months later, with mitral incompetence and congestive heart failure. He had a mitral valve replacement and made a good recovery, but was left with quite marked left ventricular dysfunction.

Negligence alleged

Initially, the patient made a claim for negligence against his dentist for not providing antibiotic prophylaxis during the dental scaling. The claim was then widened to include the GP partnership. The allegation against the GP, who was a member of the MDU, was that he had failed to make a diagnosis of bacterial endocarditis, which had resulted in damage to the patient's mitral valve.

As a result of the alleged negligence of all those named, the patient had to retire earlier than expected and his quality of life had been reduced.

Expert opinion

The MDU consulted experts in general dental practice, general practice and a consultant cardiologist on behalf of the GP. The dental expert said: 'Prophylactic antibiotic cover should have been prescribed.., it is extremely difficult to avoid gin-gival damage when scaling any patient...It would be difficult to resist a claim of negligence...'. Both he and the GP expert felt that the major failure was by the dentist.

The GP expert felt that it is notoriously difficult to diagnose infective endocarditis in its early stages when the symptoms are usually vague and non-specific. He therefore felt that the GP's management of the patient was reasonable, though given the patient's history he might have been expected to think of this diagnosis earlier. The cardiologist was of the opinion that while there had been a delay on the GP's part in referring the patient to hospital most of the damage done to the mitral valve would have already occurred.

Outcome of claim

After discussion with the other defence organisation the claim was settled for £108,000 (5 per cent MDU (to reflect the possible damage caused by the delay in referral to hospital); 95 per cent the other defence organisation).


This guidance was correct at publication 01/01/2002. It 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.

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