Seeing double

The scene

A 30-year old woman first contacted the practice nurse following a traumatic injury to her right eye. She told the nurse she had walked into a door, and the nurse treated her accordingly, bathing the injury and applying an eye patch. The nurse noted considerable swelling and hyphaema. In fact, the patient had been head butted by her partner.

Still in considerable pain four days later, and now seeing double, the patient consulted her GP. After careful clinical examination, the doctor found periorbital bruising and a subconjunctival haemorrhage, but no bony abnormality or palpable infraorbital step. He was concerned that the patient was experiencing diplopia in all directions, but advised waiting for the eye to settle.
Later that day, the GP phoned the ophthalmology department at the local hospital and explained the patient's history to a staff grade ophthalmologist, who confirmed that a fracture of the orbit was unlikely and immediate referral was not necessary. The GP did not record this conversation in the patient's notes.

At the next consultation a week later, the patient still complained of diplopia, except on upward gaze. The swelling had reduced and there was no evidence of enophthalmos. The GP found the fundus remained normal, there was still no palpable infraorbital step and he was reassured that the absence of diplopia on upward gaze suggested no blow-out fracture to the base of the orbit. The GP considered the possibility that the symptoms indicated that the patient had developed a squint. He was nonetheless concerned about the continuing diplopia and decided to refer the patient for a routine ophthalmological appointment. However, the referral letter was not written and posted until 10 days later, and was not received by the hospital for a further two weeks. When the patient saw the ophthalmologist, a full five weeks had elapsed since the GP had decided to refer her.

At the out patient appointment, fracture of the orbit was confirmed. She was later referred to a consultant ophthalmologist, by which time, there was evidence of enophthalmos although her double vision had begun to improve spontaneously. She was advised that it was too late to correct these conditions surgically.

The patient subsequently brought a claim for breach of duty and causation against the GP, alleging he was negligent in not having referred her as a matter of urgency at the initial consultation because of the presence of diplopia.


The outcome

The MDU obtained a report from a GP expert on alleged breach of duty. The expert thought that, because of the diplopia in all directions, it would have been more appropriate to arrange referral at the first GP consultation. The expert was critical of our member's decision to attribute the patient's symptoms to a squint at the second GP consultation and the 10-day delay in sending out the referral letter once the decision had been made to refer for specialist opinion. In relation to the telephone consultation between our member and the hospital, the expert believed there was no need for an urgent referral to the hospital, although the GP may need to persuade a court that the conversation took place, since it was not recorded in the patient's notes.
A report was also obtained from a consultant ophthalmologist to determine whether the delay in referring the patient had caused the damage alleged. It was the expert's view that if the claimant had been referred within two weeks of the injury and remained under the care of an ophthalmologist, the spontaneous improvement in her double vision would have been identified and she would not have been referred to a maxillofacial surgeon for orbital floor repair. He concluded that there would still have been no obvious enophthalmos resulting in urgent referral for surgery, therefore the outcome would have been exactly the same. In other words, the delay in referral to hospital had not resulted in any material difference in outcome for the claimant in terms of the surgery that would have been offered.
The claimant's expert ophthalmologist disagreed. He acknowledged that even if the claimant had been seen at hospital on the day of the incident, surgery would not have been performed straight away. However, the patient would have been kept under review. If she had then been checked two weeks later, it would have been apparent she had clinically significant enophthalmos and double vision and would have undergone surgery to repair the orbital floor. Had surgery taken place in this timeframe, the patient would have been cured of enophthalmos and double vision.

The crucial differences between the experts' opinions could not be resolved. With the consent of the member, the MDU made an offer to the claimant of £7,000 on the basis she could still have extra-ocular muscle surgery to improve her vision and cosmetic appearance. After some negotiation and counter-argument, the claimant's solicitors accepted the compromise offered.

This page was correct at publication on 21/12/2010. 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.