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16 July 2018
The MDU defended a GP member in a high value case concerning an alleged failure to refer to hospital for suspected endocarditis, which resulted in the patient suffering an acute ischaemic stroke several weeks later.
The patient had a history of aortic stenosis and an aortic valve replacement, and saw the GP member with a six-month history of cough, malaise and feeling 'out of sorts'. A blood test revealed higher than usual CRP and ESR readings, as well as a mildly elevated neutrophil count; the chest X-ray was reported as clear. A week before this consultation, the patient attended the walk-in centre and was noted to have an intermittent tachycardia, but this resolved.
The results were reviewed by the GP, who asked the patient to come in for a routine appointment in order to further investigate the raised inflammatory markers. At this appointment the patient was seen by a different GP, who asked for more tests with a view to excluding early inflammatory arthritis.
The second set of blood tests was reported as essentially normal. The second GP discussed the test results with the patient at another review, where the patient was noted to have been pyrexial the evening before, following an influenza vaccination the previous week. The patient complained of coughing, aches and pains, but on examination their temperature was normal. The second GP prescribed antibiotics and advised the patient the recent blood tests were essentially normal.
Shortly after this consultation the patient suffered a stroke and was admitted to hospital, with a history of being unwell for one to two months with non-specific malaise and lethargy. The hospital made a diagnosis of endocarditis and a CT brain scan showed a large area of infarction.
The patient brought a claim against the MDU GP member, seeking over £1 million in damages. The allegation was that on reviewing the results from the initial consultation, no reasonably competent GP would have failed to be concerned that the patient could have a serious illness, especially taking into account the patient's past history of an aortic valve replacement.
In view of the patient's symptoms and history of fever and tachycardia, it was argued that no reasonably competent GP would have failed to consider infective endocarditis as part of the differential diagnosis, and that a review of the raised inflammatory markers should have led to a referral to hospital to check for infective endocarditis.
The patient complained of coughing, aches and pains, but on examination their temperature was normal.
The MDU defended the member throughout the claim and the case was heard at trial. The judge described the member as an impressive witness, who considered their answers and came across as a careful and conscientious clinician.
The member said that while infective endocarditis was part of their differential diagnosis, from a long list of potential conditions, there were no cardinal signs such as persistent fever, night sweats, weight loss, tachycardia or a heart murmur. Having considered the blood test results, the raised inflammatory markers could have been due to a variety of possible causes.
The member believed that the patient's condition needed further clarification and assessment, and that the raised CRP and ESR were not in themselves significant, given that the patient had recently suffered from diverticulitis and a possible urine infection.
The judge held that given the mortality and morbidity risks of infective endocarditis, if there were reasonable grounds to suspect it in a patient with a prosthetic valve, a GP would be falling below the standards of a competent doctor if they failed to refer that patient to hospital.
However, the judge also said that there was very little to suggest that the complaints were due to infective endocarditis at the patient's first consultation. The blood test result showed non-specific inflammatory markers that needed further investigation, and the member put this in place by arranging a further appointment. The judge concluded that when reviewing the blood test results, the MDU member did have infective endocarditis in mind as a possible, if unlikely, diagnosis.
The response to direct another routine appointment rather than immediate admission to hospital was deemed to be that of a competent GP, and judgment was made for the defendant.
This guidance was correct at publication 16/07/2018. It 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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