Werewolf contact lens causes eye infection
A GP contacted the MDU after receiving a letter of claim regarding an alleged missed diagnosis of a corneal ulcer. While working for the out of hours service over Halloween the doctor saw a young man with a sore, red eye that had begun to hurt earlier that day.
The patient explained that he usually had perfect vision but had dressed up as a werewolf for a fancy dress party the night before - including wearing wolf eye contact lenses - and that this morning his eye was painful, gritty and red. These symptoms had worsened throughout the day and he had now noticed some yellow discharge.
The GP examined both eyes with an ophthalmoscope but did not record visual acuity or use fluorescein. They diagnosed conjunctivitis and prescribed chloramphenicol. The notes were brief and no safety netting advice was documented although the GP said this was provided.
The following day, the patient attended A&E due to the pain. They had not sought help sooner despite worsening symptoms as they understood the antibiotic drops might take time to work. The A&E doctor noted the vision was down to counting figures in that eye compared to 6/6 in the other eye. Fluorescein examination revealed a large corneal ulcer which was subsequently confirmed as a pseudomonas ulcer.
The letter of claim outlined that the patient had been left with significant scarring on his left cornea, with permanently reduced visual acuity. It alleged that had the GP assessed the vision and examined the patient properly they would have identified the ulcer earlier meaning the patient would have received appropriate treatment and had a better outcome.
The expert instructed by the MDU felt that the damage to the patient's vision could have been avoided had an earlier referral been made. It was agreed with the member that the claim should be settled due to the patient's reduced vision.
While it was difficult to determine how different the outcome would have been if the patient been diagnosed earlier by the GP, the member took away several learning points.
- The importance of being aware of corneal ulcers as a cause of red eye in contact lens wearers particularly those who are new to wearing them and whose lens hygiene may be poor.
- The need to test and record visual acuity in patients with eye complaints.
- The need to be aware of relevant guidance, such as the RCGP clinical fact sheet on conjunctivitis which advises GPs should, "Make a habit of routinely asking whether soft contact lenses are worn. If available, use topical fluorescein to identify corneal staining (epithelial defect). Refer urgently if suspected corneal ulcer, and not give antibiotics in the interim as this may interfere with a subsequent corneal culture. Aim to have a low threshold for referral."
- In addition to giving safety netting advice, the details should be documented in the patient's records in case this point is disputed at a later date.
Pumpkin carving dangers
A Foundation Year 2 doctor (FY2) who was working in A&E contacted the MDU after receiving a complaint. During an October shift a 27-year old guitar teacher had attended with a cut to the palm after a slip with a knife while pumpkin carving. The cut appeared superficial and the doctor examined the patient to confirm they could flex all fingers on that hand. There did not appear to be any tendon damage and therefore the doctor sutured the cut and advised the patient on after care.
A few days later the patient was playing guitar and felt something give after which they were unable to fully flex their index finger. They needed surgery and the hand surgeon advised there was likely to have been a partial laceration of the flexor tendon when they were seen in A&E.
The patient complained that the FY2 doctor's assessment had been incomplete. The MDU adviser helped the doctor to draft a complaint response and suggested she discuss the case with her educational supervisor to confirm if she should have tested for flexion against resistance. She could consider any local and national guidance such as the RCEM earning piece on soft tissue injuries of the hand which detailed the specific tests to do in such cases.
The doctor added the outcome of this discussion to her complaint response. This acknowledged that the patient should have been asked to flex each finger against resistance to check for a partial tendon laceration. She also identified other aspects of hand examination that would be incorporated into future practice.
The patient was satisfied with the response as he felt the doctor had recognised and taken steps to remedy the gaps in her knowledge.
Spider bite complications
A GP contacted us after a patient complained to NHS England (NHSE) that he had not been seen in a face-to-face consultation for a presumed spider bite during the COVID-19 pandemic. The patient had been working in her greenhouse when she had felt what she thought was a sting on her arm. When she brushed the area with her hand, a small brown spider fell off. Within a couple of hours a small blister had formed over the area. Over the next 24 hours the site became more painful, itchy and red.
When she called the practice about this, a telephone consultation was arranged with the GP member. The patient explained her symptoms after what she presumed was a spider bite and the GP confirmed she had no signs of anaphylaxis or sepsis. The patient reported no relevant co-morbidities such as diabetes or immunosuppression and her answers to questions about the appearance of the affected area were reassuring.
The GP asked the patient to measure the red area and draw a line around it so she could monitor if it was spreading. As she had a thermometer, he also asked her to check her temperature, and this was normal.
He advised her that it was probably a local reaction but there may be an infective element and prescribed a course of oral antibiotics and advised concurrent antihistamines. The GP also provided safety netting advice about what to do if the arm got worse over the next 24 hours.
Two days later the patient attended A&E feeling very unwell as the pain and redness has worsened. She was admitted and given IV antibiotics for cellulitis.
After she was discharged she complained to NHSE as she felt that had the GP seen her in person they would have realised how serious her condition was and arranged admission for her earlier.
The MDU adviser suggested the practice hold a significant event audit (SEA) meeting to establish if GP colleagues felt there were any learning points or if they felt the management had been appropriate at the time. The outcome of this was a consensus that the doctor's assessment and note taking had been very thorough and of a good standard.
With the help of the MDU a response was drafted and sent to NHSE which included the SEA outcome. The member commented that his personal reflection was that he could have asked the patient for a photograph of the area or conducted a video consultation to visually inspect the site. However, based on the detailed description of the area given to him by the patient at the time, his management may well have been unchanged by this.
NHSE forwarded the response to the patient and the complaint did not go any further.
This page was correct at publication on 30/10/2020. 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.