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Hidden injury

01 January 2009

Mr Y, a 46-year-old gas engineer, crashed his car into an oncoming vehicle at moderate speed (each vehicle travelling at about 20 mph). He was taken by an emergency ambulance to the nearest hospital. Mr Y reported chest and abdominal pain. Examination at the time only revealed localised tenderness and superficial bruising in a pattern consistent with injury from his seatbelt. He was observed for three hours in the department and sent home when his vital signs were normal.

The next morning, Mr Y was in a lot of pain and phoned his GP surgery. He spoke to Dr T who documented the accident in detail, Mr Y’s injuries and his subsequent symptoms. Dr T specifically recorded that Mr Y had suffered no shortness of breath, no loss of consciousness or faintness, but had “pain everywhere” and was very stiff. Dr T arranged for a prescription of co-codamol 30/500 to be left for collection by Mr Y’s daughter. He also advised Mr Y of the need to return to the A&E department if his symptoms were not better a few hours after taking the painkillers.

The next day, Mr Y was taken to hospital after a 999 call from his daughter, who had found him in acute agony with severe abdominal pain when she had gone to visit. Mr Y died shortly after his admission to hospital. A postmortem examination revealed that he had suffered a small intestinal perforation and subsequent peritonitis. Mr Y’s daughter launched a claim against Dr T and the hospital.

Expert opinion

A GP expert felt that Dr T’s telephone consultation had been thorough and well documented. Dr T had little reason to suspect the relevant pathology, given that Mr Y had previously been assessed in hospital, where such a diagnosis ought to have been considered. The expert noted that Dr T had acted appropriately and had advised Mr Y to seek further help if his symptoms persisted.

Mr Y’s daughter disputed that her father had denied shortness of breath. However, Dr T’s clear documentation of this provided strong evidence that he had considered this symptom in his clinical history, and that he had received a negative answer. Dr T was dropped from the claim for negligence, which proceeded against the hospital, on the grounds that insufficient assessment and investigation was undertaken prior to Mr Y’s discharge. The hospital eventually settled the claim for a substantial sum.

Learning points

  • Dr T’s thorough and clearly documented telephone consultation meant that his decision-making processes could be reconstructed and the claim could be defended. It is essential that extra care is taken when consulting by telephone, and that the interaction is adequately recorded.
  • The specific noting of symptoms, including negative ones that would cause a clinician concern, are important in all clinical histories, but particularly so for telephone consultations.
  • Where there is a clear contemporaneous note of a negative symptom, this gives compelling evidence that the doctor’s account of events is correct, should there be a subsequent dispute from the patient or their family.
  • Intestinal perforation following blunt abdominal trauma is a rare but recognised complication that should be considered.
  • Patients discharged from care following trauma should be given clear instructions to return for assessment if certain symptoms persist or emerge later.