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Common can be complicated

01 January 2014

Miss G, 11 years old, was taken by her mother to see GP Dr A with coryzal symptoms and a discharging right ear. She appeared quite well during the consultation, so Dr A advised symptom control measures for otitis media and advised she return for review in a week.

A week later, the patient was feeling worse, complaining of ear ache and neck stiffness and a poor appetite. Dr A reviewed her as planned and documented a negative Kernig’s sign with no evidence of photophobia or rash. He prescribed antibiotics and reassured her that she should recover soon – but that she should return again if she became any worse.

Miss G continued to deteriorate over the next few days, prompting her mother to call the clinic. She spoke with the nurse adviser, explaining that her daughter had no energy and had developed problems with her vision. The nurse told her not to worry and reassured her that these symptoms were consistent with glandular fever, and to come for a review if symptoms were persisting after a week.

Four days later, the patient’s mother called the surgery to request an emergency appointment and again spoke to the nurse adviser. She was informed that there were no appointments available until the following afternoon. Neither of these telephone consultations were documented in the case notes.

The following day, Miss G attended her emergency appointment with Dr A. Her mother explained that she had been getting worse all week and at one point experienced temporary loss of vision. Dr A noted she had an unsteady gait when she entered the clinic, and on examination had fixed pupils with marked papilloedema. He arranged immediate admission to hospital.

The paediatric team documented palsy of cranial nerves 3, 4, 6 and 7 with gross papilloedema, and arranged urgent imaging. This confirmed a cerebral sinus venous thrombosis and a middle ear infection with a right mastoiditis. She was transferred to the neurosurgical unit for thrombolysis, CSF drainage and acetazolamide, and discharged a month later.

The family lodged a negligence claim against Dr A, stating that he failed to refer for urgent investigation following their second consultation. They asserted that had Miss G received earlier treatment, she would not have suffered from reduced visual acuity or frequent headaches.

Expert opinion agreed that, based on Dr A’s account of events and the subsequent notes made by the hospital regarding the onset of visual symptoms, he performed an appropriate examination and provided a reasonable standard of care during his second consultation.

However, it was evident from the course of events that Miss G did deteriorate and the emerging visual symptoms allegedly reported to the nurse adviser did demand an urgent assessment. Failure to arrange immediate review fell below a reasonable standard of care and Dr A and his practice carried vicarious liability for this error.

Miss G’s family alleged she was unable to use public transport unaccompanied due to her persistent symptoms, which would hinder future employment prospects. MPS’s legal team made use of video surveillance in this case, which provided evidence that Miss G appeared very comfortable using public transport independently. This reduced the final settlement offer significantly, although the case was still settled for a substantial amount.

Learning points

  • The importance of documenting every consultation, including telephone consultations, is highlighted once again with this case. Disciplined documentation of every clinical encounter means that when a claim or complaint arises, you can feel more confident defending your position.
  • A reminder regarding telephone consultations is that arrangements should be made for face to face review if any concerns are raised regarding a patient’s clinical condition.
  • A patient who develops new symptoms should be reassessed and the diagnosis reviewed. In this case the nurse should not have made a new diagnosis of glandular fever over the telephone without arranging for the patient to be seen.
  • This case is a reminder that common ailments can develop rare complications. The majority of cases of otitis media seen in general practice will resolve without complications; however, health professionals should remain vigilant to the possibility of disease progression. Safety netting measures protect you and your patient.
  • Asking the patient to attend for a review is an important safety net to put in place, but it is important to be able to follow this up. Lack of available GP appointments means that clinical staff are often in the position of triaging patients without seeing them in person, which can lead to a deteriorating patient being overlooked. Clinical staff should be trained to spot red flags and be aware of developing symptoms that require immediate review.
  • Mastoiditis is now relatively rare. The incidence of the condition following acute otitis media reduced from 50% to 0.4% following the introduction of antibiotics.1 Prior to this, mortality rates were two per 100,000 compared to <0.01 per 100,000 now.2

References

  1. Jose J, Coatesworth AP, Anthony R, Reilly PG, Life threatening complications after partially treated mastoiditis, BMJ; 327:41 (2003)
  2. Bluestone CD, Clinical course, complications and sequelae of acute otitis media, Pediatric Infectious Disease Journal; 19(5 Suppl):S37-46 (2000)
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