A patient in his late 40s saw an independent MDU GP member for a DVLA assessment in 2002. This GP wasn't the patient's regular doctor, and performed an examination as a precondition to the return of the patient's driving licence.
The patient had been banned from driving for 12 months, having failed a breath test and being found significantly over the legal alcohol limit. His blood pressure was recorded on the DVLA form as 182/105.
Some five years later the patient was seen by his own GP, whose note recorded 'See pn [practice nurse] for BP review.' Despite this recommendation the patient didn't have his blood pressure checked and went on to suffer a minor stroke a few years later.
The patient was advised to stop drinking and smoking but suffered a further stroke the same year, which proved fatal.
A claim was pursued by the patient's wife on behalf of the estate, alleging that during the DVLA examination, the MDU member failed to advise the patient to have his blood pressure checked by his own GP and diagnosed the patient with 'white coat hypertension'. It was also alleged that the patient told his wife about this diagnosis afterwards and that his high blood pressure may have been because of his anxiety about the appointment.
The GP had no memory of the consultation and relied on his habitual practice in defence of his actions. He confirmed that the DVLA provided a printed form for completion by the examiner, which doesn't have to be included in the patient's GP records. The form didn't invite any comments and allowed no room for individual observations or notes by the examiner.
The GP described his typical examination, which would have included a cognitive assessment and taking the average of up to three blood pressure readings. Having established the readings weren't normal, the GP would have asked the patient about his history of blood pressure and family hypertension.
He explained in his defence that a diagnosis couldn't be made from blood pressure readings taken on a single occasion, and also confirmed that while he may have used the expression, he did not make a diagnosis of white coat hypertension. In accordance with his typical practice he would have advised the patient to consult his GP, explaining that if he did have hypertension it would need treatment.
The MDU obtained expert reports from a GP and neurologist. While the neurology experts on both sides of the case couldn't agree to what extent the risk of stroke was increased by hypertension, they acknowledged that there would nevertheless have been an increase. None of the experts were able to say that had the patient been seen by his GP following the DVLA assessment, on the balance of probabilities his blood pressure reading would have been raised.
The claimant argued that because the patient's untreated hypertension carried an increased risk of stroke, it materially contributed to the subsequent strokes. The case eventually went to trial for the judge to determine the facts.
The court found in favour of the GP on the facts, and that he advised the patient to have his blood pressure checked by his own doctor.
The court found in favour of the GP on the facts, and that he advised the patient to have his blood pressure checked by his own doctor. It also accepted that the GP did not make a diagnosis of white coat hypertension. On factual causation, the court held that the patient was given advice to attend his GP to have his blood pressure checked and didn't do so. It also found that the claimant had failed to prove that any subsequent blood pressure reading would have been raised.
The court determined that even if the GP had breached his duty of care by failing to advise the patient to have his blood pressure monitored by his own doctor, this would not have altered the outcome. The judge confirmed the 'but for' test applied, which asks, 'but for the existence of x, would y have happened?'
In light of the patient's lifestyle the judge also commented that even if the court had found the GP to be liable, any damages would have been reduced by 25%. This reflected contributory negligence on the part of the patient for failing to have his blood pressure checked when advised to do so by his own GP five years after the DVLA assessment. The claim was dismissed and the MDU recovered the costs of defending the matter to trial.
The doctor's perspective
I was acting on behalf of the DVLA but I also had a duty of care to the patient, which I carried out by advising him to go to his GP for further blood pressure checks. If I had added next to the raised BP recording on the patient's medical examination form, 'Patient advised to see own GP for further BP check.' even though there was no space for this, that would have been the end of it. Alternatively, with his permission, I could have sent a brief letter to his GP.
I had always assumed that the DVLA would report significant abnormal findings found at their medicals to the patient's GP, much as insurance companies do, but even if that is their policy, clearly that wasn't the case here.
I relied on the patient following my advice but he didn't. Should I have written to his GP as well? The court clearly thought I did not need to. Part of me feels I should have, but part of me feels he had a right to ignore my advice, if that was what he wanted to do.
My trainer always said to me that I would be judged by my reputation, with the implication that you did not need to worry too much about defensive medicine if you are a good and caring doctor. This is probably less true now but I suspect the case would not have been made against me if I had been the patient's regular doctor.
This page was correct at publication on 14/03/2017. 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.