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Monitoring fails; kidney fails

01 November 2003

As a young man, Mr T had bouts of flank pain and haematuria. Repeated dipstick testing of his urine showed evidence of haematuria and proteinuria. This was investigated by a urologist, with no cause being found. A few years later he had episodes of gout, receiving NSAID treatment.

When he was 30 he registered with a new practice, seeing Dr S, who noted his gout and treatment with NSAIDs, and previous investigations for haematuria. Later, at a routine insurance medical, dipstick testing revealed haematuria and albuminuria, and this prompted Mr T’s referral to Dr H, a renal physician.

Dr H suspected that Mr T had mild, chronic glomerulonephritis. Mr T was unwilling to undergo renal biopsy and so a follow-up appointment was arranged for a year later. He failed to attend, despite several reminders. Dr H wrote to Dr S asking him to check Mr T’s BP, U&E, creatinine and MSU annually.

Mr T attended on a few occasions over the next couple of years with attacks of gout. Each time, prescriptions for NSAIDs were issued. Between 1990 and 1998 repeat prescriptions for NSAIDs were issued more than 80 times. During the last four of these years, Mr T didn’t see any member of the practice. He wasn’t maintained on a therapeutic dose of allopurinol and no checks were made of his renal function.

In late 1998 Mr T attended the surgery complaining of nocturia, and investigations revealed evidence of renal failure. He was referred urgently for a further renal opinion. He was diagnosed with chronic renal failure secondary to glomerulonephritis and had a renal transplant soon after.

A legal claim was launched against Dr S and his partners, alleging negligence for failing to monitor Mr T’s renal function, failing to adequately treat or investigate his gout and for prescribing NSAIDs, which worsened his condition.

Expert advice

Expert advice was critical of the failed monitoring of renal function.

The treatment of the gout, without adequate prophylactic therapy or referral for advice, was also held to be below an acceptable standard. It was uncertain whether the prolonged use of NSAIDs had led to a worsening of the renal failure over and above that caused by the glomerulonephritis, but this possibility could not be discounted. The claim was settled for a sizeable sum.

Learning points

Practices need adequate systems in place to deal with issues such as repeat prescribing and monitoring infrequent tests.

  • Repeat prescribing – the computer system used by the practice did not record which doctor had authorised repeat prescriptions or whether the patient had been asked to see a doctor before the prescription was authorised. Setting regular reviews of repeat prescriptions ensures that the medication is appropriate, and that patients use the medication correctly. In 200 Clinical Risk Self-Assessments facilitated by MPS Risk Consulting, repeat prescribing was identified as an area of risk by 75% of practices.IT systems are far from perfect, and are not the only solution to a particular administrative task.
  • Irregular tests – where specific recommendations for infrequent tests are advised, a system of recall must be set up to ensure this happens. Relying on chance is unlikely to be sufficient.
  • Renal impairment and liver disease – both these conditions alter the response of the body to drugs in several ways. In the UK, the BNF (www.bnf.org) contains an appendix of precautions and contraindications when prescribing for these patients.
  • Shared risk – GPs in a practice share the risk and responsibility of setting up systems.