A GP member received a letter from solicitors instructed by a patient who had attended the surgery three years earlier. The letter alleged the patient had suffered permanent hearing loss in one ear after the original consultation, and that if an urgent referral to the ENT surgeons had been made at the time, this wouldn't have occurred.
The member contacted the MDU for advice and provided copies of the medical records, along with a report of the consultation which was subject to criticism. The patient's primary complaint at the time had been of nausea and vomiting, as well as left-sided earache and some dizziness. According to the member's records, the patient's abdomen was soft and non-tender with normal bowel sounds. After examining the ear and noting that the eardrum appeared red, the GP prescribed amoxicillin.
A week later the patient saw a different GP, and complained of deafness in the left ear. He was referred to the ENT surgeons and seen two months later, at which point he was diagnosed with left-sided sensorineural hearing loss which did not recover.
It was alleged in the letter of claim that with earlier referral to the ENT surgeons, the patient would have been treated with corticosteroids and his hearing would have been preserved.
The MDU sought advice from an independent GP expert, who said that a GP faced with a complaint of sudden hearing loss has a duty to consider whether it is sensorineural or conductive. The former may have an underlying serious cause and require further investigations, whereas the latter is normally not serious and can be due to an upper respiratory tract infection leading to catarrh in the hearing passages of the middle ear.
The patient said that he had complained of hearing loss at the consultation, but the GP member had made no record of this complaint. The GP expert advised that if a complaint of hearing loss was made then the GP had a duty to investigate it further, including whether there were any associated symptoms, and to consider carrying out tuning fork tests to look for conductive deafness. If no complaint was made then no further referral was necessary, but any possibility that the patient had suffered sudden sensorineural hearing loss required an urgent ENT referral.
The MDU also obtained independent expert advice from a consultant ENT surgeon, who stated that in retrospect, the most likely underlying diagnosis was acute labyrinthitis. When the patient was seen by the ENT surgeons, he was diagnosed with profound hearing loss. The ENT expert explained that reviews of steroid treatment in sudden sensorineural hearing loss confirm that the value of such treatment is unclear, and the evidence is contradictory.
Although there are some case reports that suggest hearing improvement from treatment with steroids in sudden sensorineural hearing loss, the expert stated that this may be due to spontaneous recovery, and even these reports indicate that if the hearing loss is profound, as in the patient's case, there is no useful hearing improvement. Therefore, the ENT expert said that on the balance of probabilities, even if an earlier ENT referral had been made the outcome in terms of the patient's hearing loss would have been the same.
A copy of the ENT expert's report was provided to the patient's solicitors, and given the strength of the position in respect of causation – that earlier treatment would not have made any difference to the outcome – the claim was discontinued.
In this case there was a dispute between the patient's position – that there had been a complaint of hearing loss made to the member – and the GP's, which was that no such complaint was made.
A dispute on the factual case can mean there is some risk for both parties in the claim, since ultimately a judge might prefer the evidence of one party over that of the other. Because of this it's important to record significant negative findings in the records since this can assist in resolving a factual dispute in favour of the doctor.
In this case, the strong expert evidence obtained on causation by the MDU meant that the claim was discontinued, but if this had not been the case then the outcome may well have been different.
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.