Full records help defence

The patient, a 25-year old woman, initially saw her GP complaining of a sore throat and a cough and was diagnosed with a respiratory tract infection.

One week later she attended an out of hours centre and saw a different GP, an MDU member. She was now pyrexial and reported coughing up yellow phlegm. The GP examined her and recorded a comprehensive note detailing all his findings. He diagnosed a chest infection and prescribed erythromycin as the patient was allergic to penicillin. He also gave the patient safety net advice.

Several days later, the patient returned to her GP surgery and saw the first GP again. By now she was experiencing pain in the left side of her chest. On examination, nothing abnormal was found; however, the GP noted that her condition was deteriorating despite the erythromycin she was taking.

The patient then developed a raised red rash and returned to see her GP again. The GP diagnosed pneumonia and referred her to hospital. She subsequently underwent rigid bronchoscopy, a left thoracotomy and decortication of a left-sided empyema. At surgery there was noted to be a lung abscess in the middle and lower lobes, heavily consolidated.

In the subsequent claim for negligence, the patient alleged that she had reported haemoptysis at the second and third GP consultations. There was, however, no note in her records to support the allegation. The MDU out of hours GP stated that he had made very careful notes and would have recorded haemoptysis as an important symptom if the patient had reported it.

The MDU instructed experts in general practice and respiratory medicine to comment on the management provided to the patient by the MDU member. The experts were supportive of his management. A response was submitted to the claimant's solicitors denying liability on behalf of the MDU GP member on the basis that the member had written a detailed comprehensive contemporaneous record, that the report of haemoptysis was denied and that the member provided prompt and correct safety net advice.

The respiratory expert thought that it was likely that at this point the patient was developing pneumonia although at this time it would have been very difficult to diagnose clinically and if a chest x-ray had been performed, it would very likely have been abnormal.

The patient's solicitors indicated their intention to take the matter to court. Although the first GP elected to settle the claim, the action was not pursued against the MDU member and our defence of the case was greatly assisted by the comprehensive clinical record he had made during the consultation and supportive expert evidence obtained on his behalf.

This page was correct at publication on 04/12/2013. 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.

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