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A challenging combination

01 January 2013
This case is based on incidents that took place in the UK

Mr Y was a 21-year-old unemployed man who lived with his mother. He was a heroin addict and in the last few months, he had started injecting into his groin. Each day he was spending about £40 on heroin and cocaine and had recently served a prison sentence for burglary to fund his habit.

Mr Y was well-known at the practice as he had attended since his childhood. The practice had supported him and his mother with some behavioural problems at school and with issues around domestic violence before his father had left home. His mother had schizophrenia and was also a regular attender at the practice.

Both Mr Y and his mother had been the subject of discussion as practice staff were finding them increasingly difficult to manage. Lately, they had both been regularly missing appointments and were rude to staff. Mr Y frequently requested appointments for minor ailments, such as aches, pains and colds, yet upon attending he asked for methadone or pethidine. His behaviour was rather manipulative and consultations were often challenging.

During one month, Mr Y attended several times complaining of back pain and feeling unwell with flu-like symptoms. Dr S and his partners saw him and documented their history and examination. It was recorded that he was suffering with severe back pain and feeling “hot and cold”. His temperature had been recorded as 38.9 degrees. Notes also stated that he had symptoms of severe constipation and difficulty passing urine. A blood test had been arranged, which showed a significantly raised ESR and white cell count – the results were not acted upon.

Mr Y began to feel worse and was struggling to get out of bed due to the severity of his back pain. His mother attended the surgery on her son’s behalf to ask for a home visit, but one of the receptionists refused the request and asked that the patient attend surgery. She mentioned later that Dr S had said previously that “he couldn’t do any more for the family” and that she was trying to help.

The next day Mr Y felt very weak. He tried to get out of bed and collapsed. His mother called an ambulance and he was rushed to hospital. He was diagnosed with endocarditis and discitis. Despite intravenous antibiotics he died of overwhelming sepsis. His mother was devastated and made a claim against Dr S’s surgery. The case could not be defended and was settled for a moderate amount.

Learning points

  • Frequent attenders can and do have serious illnesses; doctors must not let an element of “crying wolf” blind their judgment. It is important to keep this awareness and objectivity when seeing patients.
  • When investigations are requested it is important to have a system in place to ensure they are acted upon if necessary.
  • Effective triage is an integral part of general practice and is better based on clinical need rather than catering to the most persuasive or demanding patients. An effective triage system could help direct patients to the most appropriate appointment at the most appropriate time, and identify patients who have an immediate medical need.
  • The management of patients who are drug users raises issues that may need discussing within the practice to offer better care. For example, there should be an awareness of the guidelines to support patients with addiction including where and how to refer patients for support and/or detoxification, and offer "shared care" for the management of drug misuse.