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A growing problem

01 January 2009

The right of Sandy Anthony to be identified as the author of the text of this work has been asserted by her in accordance with the Copyright, Designs and Patents Act 1988.

Mr S, a 41-year-old shop manager, had been experiencing frequent headaches for a year; as he was not responding to treatment, his GP referred him for specialist opinion. At the outpatient clinic, Mr S saw a consultant in neurology, Dr F, who took a comprehensive history and made a thorough examination, finding no focal signs. He diagnosed migraine and tension headaches, for which he prescribed an NSAID.

Over the next five years, Mr S’s headaches not only persisted but became more intense, and he consulted Dr F on three more occasions. At each of these consultations, Dr F examined the patient carefully and took a comprehensive history before prescribing a change in medication for migraine.

On his last visit to Dr F, Mr S commented that his face felt somehow different and that he was experiencing pain in his jaw. Dr F suspected that a dysfunctional temperomandibular joint might be causing or contributing to Mr S’s headaches and wrote to his GP, suggesting that he arrange for Mr S to see a maxillofacial surgeon. The GP referred Mr S to Mr H, a maxillofacial specialist.

Mr S’s history, which included a painful jaw, thickening of the skin and a change in his facial features over the past few years, led Mr H to suspect acromegaly so he arranged for a CT scan, x-rays and blood tests. The results of the tests confirmed the diagnosis, with the CT scan showing the presence of a macroadenoma in the pituitary gland.

Unfortunately, even following surgery to remove the tumour, Mr S continued to experience problems related to elevated levels of growth hormones and his life expectancy was significantly reduced. He brought a claim against Dr F, alleging that he should have arranged for a CT scan, given Mr S’s persistent headaches.

Expert opinion

On the question of liability, an expert in neurology supported Dr F’s approach. He observed that, although some neurologists might organise imaging in a case of persistent tension-type headaches in the absence of physical signs, there were equally many who would not.

Regarding causation, an endocrinologist examined the facts of the case and concluded that the outcome would have been similar for Mr S, even if he had been diagnosed and treated three or four years earlier. Following the exchange of expert witness reports, Mr S discontinued the claim.

Further reading

  • JAH Wass, MN Carson and PR Bates, The Changing Patterns of Presentation and Treatment of Acromegaly in the UK as Reflected by the UK National Acromegaly Database, Endocrine Abstracts 7: 125 (2004).
  • Nachtigall, L et al, Changing Patterns in Diagnosis and Therapy of Acromegaly over Two Decades, Journal of Clinical Endocrinology & Metabolism 93(6): 2035–41 (2008).

Learning points

  • Acromegaly is a rare condition that is difficult to diagnose. The reported average time taken to reach a diagnosis from the onset of symptoms varies, but ranges from 4 to 12 years.
  • This case illustrates the application of the Bolam principle. Even though some clinicians might have sent Mr S for a scan, it does not follow that Dr F was negligent. His management of Mr S would accord with the normal practice of many of his colleagues, and therefore is supported by “a responsible body of professional opinion”.
  • The causation issue in this case is also significant. Even if Dr F had been liable for the delayed diagnosis, no harm flowed from the delay and thus no entitlement for compensation.