Ophthalmic case study

A 75-year-old woman lived alone, without the need for any help from social services or her family. Over three months, she presented on three occasions to different GPs, complaining of stiffness in the neck and shoulders, and occipital headache.

On the first occasion, neck examination revealed no abnormality apart from mild stiffness and mild limitation of movements. Cervical spondylosis was diagnosed and reiterated at the subsequent consultations. At the last consultation, the GP also documented pain in the right jaw.
 
Ten days later, on a Saturday morning, the patient presented to the A & E department of the local hospital with a one-day history of painless loss of vision in her right eye. The A & E trainee doctor elicited the three-month history of neck symptoms and occipital pain but not the history of jaw pain, and noted that visual acuity in the right eye was limited to counting fingers with an abnormal fundal appearance. ESR was 45 mm/hr.
 
The case was discussed with the on-call ophthalmology trainee. It was decided that the patient probably had a central retinal artery occlusion. Arrangements were made for the patient to be seen on the following Monday afternoon in the ophthalmology department.
 
The patient was brought to hospital by ambulance on the Monday morning having developed visual loss also in her left eye. Visual acuity was limited to counting fingers in the right eye due to central retinal artery occlusion, and hand movements in the left eye due to optic nerve infarction (anterior ischaemic optic neuropathy). The right superficial temporal artery was not tender but pulseless. The left superficial temporal artery was pulsatile and not tender. CRP was elevated at 40 mg/L.
 
GCA was diagnosed. The patient was admitted and treated with intravenous methylprednisolone followed by high-dose oral steroids, together with osteoporosis prophylaxis, long-term management being supervised by a rheumatologist. Temporal artery biopsy was positive.

The patient’s vision did not improve and she was certified severely visual impaired. Unable to return to her home, she had to be rehoused, with extensive support from social services. Treatment was subsequently required for diabetes mellitus and systemic hypertension.
 
Six months after the patient’s admission to hospital, each of the GPs received a letter from solicitors acting on behalf of the patient indicating the likelihood of a claim for clinical negligence. The subsequent letter of claim alleged that each had been negligent by:

  • not considering the diagnosis of GCA
  • not arranging urgent investigations or urgent hospital referral
  • not instituting systemic steroid therapy

It was also alleged that the patient’s diabetes mellitus and systemic hypertension were a direct consequence of the GPs’ negligence.
 
The GPs had a group membership with the MDU. A GP expert, instructed by the MDU to provide a report on breach of duty, was critical of the GP who had elicited the history of jaw pain. He considered that it would be difficult successfully to defend the failure to refer on this date.
 
An ophthalmology expert concluded that institution of oral systemic steroid therapy at any time before the onset of visual loss in the right eye would probably have prevented any visual loss in either eye. He criticised the hospital’s failure to institute high-dose systemic steroid therapy on the day of presentation to A&E, which would probably have avoided any loss of vision in the left eye.
 
A rheumatology expert advised that the development of diabetes mellitus and systemic hypertension would have happened in any case and could not be ascribed to the delay in starting systemic steroid therapy.
 
The case was settled jointly by the MDU, on behalf of the GPs, and the hospital on the basis that there had been unreasonable delay in diagnosis and institution of treatment of GCA by both the GPs and the hospital. A large settlement was necessary because of the patient’s rehousing and care needs.

This page was correct at publication on 01/12/2007. 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.