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Slipping through the cracks

01 September 2012

Mr F, a 45-year-old executive manager in a major sales company, saw his GP, Dr D, for a cold. The GP noted from the records that Mr F had attended the Emergency Department three times prior to this for minor ailments. His blood pressure that day was 150/90mmHg and his BMI was 36. Dr D arranged a cholesterol test, gave some lifestyle advice and asked him to reattend to recheck his blood pressure. Mr F did not attend the follow up appointment with the healthcare assistant for a blood pressure check.

Six months later, Mr F attended surgery again and was seen by a different doctor in the same practice. Looking at the notes, the patient had attended multiple walk-in centres and received treatment for minor ailments six times since his last attendance at the practice. His cholesterol was significantly raised on the blood test taken six months ago and it appeared a note had been sent to the patient to come in to discuss the result.

When asked about this, Mr F explained that he had received the note but that he had had the same test done at his in-house occupational health department, with whom he had discussed the result, and that he had been also seeing them for minor ailments. Once again, Mr F’s BP was raised but was significantly higher than before and the GP was concerned, despite Mr F’s protests that it was likely because he was a “bit stressed”. The GP and Mr F discussed the best management option and the GP decided to refer Mr F to cardiology based on this high reading, and started Mr F on an antihypertensive. Mr F failed to attend the outpatient appointment.  

Two months later, Mr F had an episode of indigestion. At the consultation with his occupational health doctor, when asked whether he was on any medication, Mr F said he was taking none. He was given antacids. However, he continued to have pain for three days on and off. He then suffered a cardiac arrest and unfortunately could not be resuscitated. The postmortem showed myocardial infarction.

Looking back over his notes, there had been repeated blood pressures recorded in his notes from various appointments at the practice, the occupational health department, emergency and out of hours services, and readings had been steadily increasing, without the instigation of a proper management plan and with inadequate follow up. A claim was made against all doctors involved. The case was settled for a substantial sum reflecting Mr F’s age and the fact he was a high earner.

Learning points

  • When patients use multiple health systems for care, there is a risk of concern for their symptoms being diluted by spreading the consultations across a number of healthcare providers. This can be a particular problem with people with demanding jobs, and where employers provide a work-based health service. It is important to work together and communicate with colleagues. The occupational health service should inform the patient’s GP, with the patient’s consent, and it should be clear who will be following up – usually the GP.
  • When patients attend the ED multiple times for minor ailments, it may be worth addressing this in the consultation and explaining alternatives, to avoid a lack of continuity of care.
  • Any advice given to non-compliant patients should include the risks of failing to take medication or attend appointments, and should be documented.
  • Arranging follow-up for any appointments missed or medication started makes practice safer. In this particular case, the patient missed an outpatient appointment and a GP appointment and was not followed up for either non-attendance to find out what happened.
  • With poorly compliant patients, or those who are difficult to track, it is important to take advantage of opportunistic follow-up, and perform routine checks, such as blood pressure.