Growing concern

February 2006

Barney was 13 when he first saw Dr J, GP trainee, in 1990. Barney’s mum had asked for a home visit as her son was vomiting a lot. She was also concerned that Barney was small for his age. Dr J found no evidence of significant intra-abdominal pathology. Dr J asked Barney and his mum to attend the surgery so he could be weighed and measured.

At this review Dr J established that Barney’s height and weight lay between the third and fourth population centile on a standard growth chart. This was a significant change from his previous growth-velocity curve, but Dr J did not refer back to a previous growth chart to ascertain this. Dr J reassured Barney and his mum that his growth was ‘in the normal range’. Dr J prescribed an antacid for Barney, believing him to be suffering from gastro-oesophageal reflux.

Over the next few months Barney came to see Dr J twice. His nausea persisted and Dr J prescribed symptomatic treatments.

Over the following year Barney came to the surgery eight times. He remained chronically nauseated, occasionally complained of headaches, had episodes of double vision and his mum repeatedly expressed her worries about his growth.

Barney was seen by Dr Z, GP principal (and Dr J’s trainer). Dr Z examined Barney’s abdomen repeatedly, checked his FBC and documented his height and weight, which were not rising as one would expect in a boy of this age. Barney was sent for a gastroscopy, which was normal.

Shortly after, Barney’s mum moved to another GP practice. The doctor Barney saw noted a history of chronic nausea and vomiting, headaches, visual disturbance, poor growth and delayed puberty; the new GP immediately referred Barney to a paediatrician.

The paediatrician found no neurological abnormality, including normal optic discs. A skull x-ray was normal, but a CT revealed a pineal tumour and secondary hydrocephalus. Barney needed a course of radiotherapy, prolonged high-dose dexamethasone and the insertion of a ventriculoperitoneal shunt, followed by a course of chemotherapy. The final diagnosis was a pineal teratoma.

Barney was cured of his tumour but suffered long-term diplopia, osteoporosis, cataracts and hypopituitarism. A legal claim naming Drs J and Z alleged that they had caused Barney 16 months of unnecessary suffering by failing to refer for advice, and that they were responsible for his restricted growth.

It was claimed that Barney’s osteoporosis and cataracts were due to the more aggressive treatment he needed, and thus Drs J and Z were responsible for these side effects. GP expert opinion was not supportive of either Dr J or Z.

Dr J was criticised for not interpreting the raw weight/height figures in the context of Barney’s previous growth chart, and referring for advice on that basis. Dr Z should have considered extra-abdominal causes for Barney’s symptoms and been prompted to refer him to a paediatrician by his constellation of symptoms.

Dr J saw Barney shortly after joining the practice and was still discussing all her patients with Dr Z during that time.

For this reason (Dr Z’s responsibility for Dr J’s clinical performance, as trainer), Dr Z was held to be 75% liable for the errors, Dr J 25% liable.

Expert opinion

Oncological opinion regarding the link between these deficiencies of care and any injury suffered by Barney was much more complex. The optimal treatment for intracranial teratoma was contentious at this time.

However, it could not be denied that Drs J and Z caused Barney unnecessary suffering and distress. The claim was settled and Barney was also paid his legal costs.

Learning points

• Growth charts – Absolute values for weight and height in a growing child are meaningless if interpreted in isolation. What is important is their relationship to previous figures for the same child, in the context of a growth curve plotted against the centile norms for children of the same gender. Any sustained ‘falling off’ from their usual centile is a cause for concern if there is no known aetiology, and it is wise to seek advice from a paediatrician.
• Reviewing the diagnosis – It bears repeating (and we have said it many times before), that having the courage to review your diagnosis, or that made by a colleague, is one of the most important attributes a doctor can possess. None of us are infallible and disease can present in surprising ways, so it is important to keep an open mind.
  In this case, Drs J and Z would have done well to remember that extra-abdominal pathology can cause nausea and vomiting. Where the triad of persistent headaches, nausea and visual disturbance occur, regardless of the patient’s age, the diagnosis is an intracranial pathology causing raised intracranial pressure, until proven otherwise.
• Listen to Mum and Dad – Where a parent is concerned about a particular symptom and frequently brings their child to a doctor because of it, it is worthy of note and you should do all you can to exclude significant disease before giving reassurance. Doctors are experts on health, parents are experts on their children. They are not always right, but then neither are doctors.
• Supervision – This case demonstrates that those responsible for training junior colleagues can be held vicariously liable for any deficiencies that the trainee may show. It is important to supervise trainees properly, train them adequately and ensure that you are confident of their safe clinical autonomy, before granting it entirely. If you take on the responsibility of training junior colleagues then you must ensure that you are sufficiently knowledgeable and up-to-date to do so.