Too little, too late

This case serves as a reminder of the importance of taking a detailed history and thoroughly investigating all angles

Mr A, a retired electrician, went to see his GP, Dr F. Recently his cousin had been diagnosed with a rare, inherited haematological condition and he wanted to know if he had it too. As part of the work-up, Dr F requested a full blood count (FBC) and serum ferritin.

The tests showed that Mr A hadn’t inherited the condition, but revealed borderline anaemia, with a significantly low serum ferritin. The anaemia was not investigated, nor were arrangements made to follow it up.

Six months later, Mr A had a private medical-screening examination. A further FBC showed persistent anaemia. A faecal occult blood (FOB) test was strongly positive. This information was forwarded to Dr F. She repeated the FBC and haematinics, finding Hb just inside the normal range. Serum ferritin remained grossly depleted. Dr F suspected this was due to a bleeding intestinal polyp and initiated no further investigation.

Two months passed and Mr A saw Dr F again, complaining of epigastric pain, which Dr F attributed to dyspepsia due to stress.

Mr A’s pain persisted, so he saw a locum GP, Dr O, who documented that Mr B’s bowel habit wasn’t altered. An abdominal examination was recorded as normal. No rectal examination was performed.

Three months after this, Mr A suffered constipation and requested a laxative. A prescription was issued and he was asked to attend the surgery. He saw a partner who, noting a five-month history of abdominal pain and the previous positive FOBs and anaemia, requested an urgent surgical outpatient opinion.

Before he was seen, Mr A was admitted to hospital as an emergency, with intestinal obstruction. He was found to have a large, stenosing adenocarcinoma of the sigmoid-colon, which had metastasised to his liver.

He died within a year of being diagnosed.

A claim alleging negligent investigation of Mr A’s test results and clinical complaints by Drs F and O, was
brought by Mr A’s family.

Expert opinion

Expert GP opinion was critical of Dr F. “The correct response to the blood test results was … to carry out aa detailed history in regard to diet and gastrointestinal complaints, conduct an examination and almost certainly to consider bowel investigation.” This was even clearer when the FOBs became available.

Dr O’s failure to relate the abdominal pain to the previous laboratory findings was similarly criticised. Surgical opinion was that had Mr A been diagnosed when he was found to be anaemic, his chances of survival would have been greater, as metastasis was unlikely to have occurred at this stage. The claim was settled.

Further reading

Unexplained iron-deficiency anaemia requires investigation. The British Society of Gastroenterology has published guidelines for the management of iron deficiency anaemia, which can be found here: www.bsg.org.uk.

NICE has produced referral guidelines for suspected cancer, available here: www.nice.org.uk. The guidance is due to be reviewed in June 2010.