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More than a bruise

01 January 2012

Mr U, a healthy 30-year-old taxi driver, was on duty when he suffered a minor road traffic accident. He was sitting at the wheel of his car at a red light, when a car hit him from behind. Mr U was wearing his seat belt, and the collision caused the seat belt to impact on his chest, which caused an abrasion and bruising. There was no damage to the other cars involved and Mr U felt no subsequent pain so, after exchanging insurance details, he continued his day as usual.

The following day, Mr U awoke with pains in his shoulder and the upper part of his chest, where the seat belt had restrained him. The pain did not have any worrying features and was very non-specific, but his wife prompted him to visit the local emergency department (ED).

On arrival Mr U had his heart rate and blood pressure checked. They were within normal limits; he was then examined fully by Dr F, a junior doctor. Dr F documented that there were no obvious abnormalities, and the chest examination was normal. As the pain seemed severe, he requested a chest x-ray, and no abnormalities were detected. Dr F reassured Mr U that he had a minor chest contusion, probably caused by the seat belt, and that it would settle down without any further problems. He also advised Mr U to take ibuprofen regularly for the next couple of days.

During the next five days, Mr U attended his GP surgery with increasing pain to the traumatised area. Mr U was seen by three different doctors. At every visit he was fully examined and his temperature, oxygen saturation and HR/BP were recorded. In spite of the severe pain, there appeared to be no change in Mr U’s condition. There were no bruises, no crepitus and the breath sounds were normal. The entries on Mr U’s records by all the doctors involved were clear and detailed. Each doctor added a painkiller of increased strength in an attempt to make him more comfortable. All doctors agreed that it was a musculoskeletal pain caused by the contusion.

Six days after the accident, Mr U felt dizzy and looked very unwell. His wife drove him to the ED. On arrival he was hypotensive and tachycardic, his oxygen saturation was low and he was feverish. Mr U was seen again by Dr F, who found on examination a large bruise on his chest. Dr F immediately started treatment with fluids and antibiotics, but as he was waiting for the blood results the bruised area seemed to grow larger than an hour earlier. Suspecting necrotising fasciitis, he called the ICU team, where Mr U was admitted.

Mr U was taken to theatre for debridement, but unfortunately he rapidly deteriorated and died from the necrotising fasciitis two days later. Mr U’s widow made a claim against all the doctors who saw her husband following the accident. The experts reviewed all the medical records and gave supportive evidence, so the decision was made to defend the case, since it was felt that the management had been correct and none of the doctors were in breach of their duties. The case was successfully defended.

Learning points

  • Sudden and unexpected death will leave questions behind that may affect the perceptions of the bereaved. Good quality records are invaluable in demonstrating that care was of the appropriate standard and reasonable in the circumstances.
  • Claims and complaints can and will happen in spite of doctors doing their jobs properly.
  • It is always safe practice to treat each patient as if they are being seen for the first time. Diagnoses made by colleagues can lead to a false sense of security and a repeat of the wrong diagnosis.
  • In this particular case, each doctor examined the patient and documented it; had this not been the case, there could have been reasonable doubt that there were symptoms or signs missed.
  • Beware of pain that is out of keeping with the clinical findings.
  • Do not be afraid to go back and rethink the initial diagnosis (whether made by you or somebody else), in light of any new evidence or if the condition is not resolving or behaving in the way you thought it would.
  • Necrotising fasciitis is not a common condition, but is still a life threatening one. Useful advice can be found at: Medscape; Dr S Hasham, Necrotising fasciitis, BMJ (2005; 330:1143).