Similarly, you should always be prepared to revisit your own diagnosis, should symptoms persist. Dr G, in “Double problem, double risk” on page 20, was distracted by Mr E’s multiple complaints and did not reconsider his initial diagnosis. The five-month delay in the diagnosis of squamous cell carcinoma of the tonsil meant that the case could not be defended. In “Too many records spoil the notes” on page 15, ophthalmology consultant Dr C failed to diagnose Mr M’s glaucoma, despite there being recurrent abnormalities in his vision and a family history of glaucoma. Listening to the patient is imperative; have an open, unbiased mind at each consultation and consider a second opinion if you are unable to account for a patient’s symptoms or clinical signs. Inaccurate record-keeping and retrospective amendments to the patient’s records made this case indefensible.
Conversely, accurate record-keeping can help to build a successful defence against a claim. We often receive feedback from members asking us to feature more successfully defended case reports; “Right patient, wrong sample” on page 17 and “More than a bruise” on page 18 are such examples. In “More than a bruise”, none of the doctors involved were found to be in breach of their duties, despite Mr U’s sudden and unexpected death. Records clearly showed the careful management of his condition, examination and documentation of symptoms. Had the records not been comprehensive, there could have been reasonable doubt that there were missed symptoms or signs.
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