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Inadequate assessment

01 February 2005

A man in his forties, Mr B, had suffered a recurrence of the pulmonary tuberculosis he had originally been diagnosed with some ten years earlier. He was being maintained on pyridoxine, pyrazinamide and rifampicin, although urine tests carried out at his periodic appointments at the chest clinic suggested his compliance was patchy.

When Mr B was seen by his GP, Dr L, his symptoms of haemoptysis and nausea sufficiently concerned the doctor to refer him to hospital - indeed, an entry in the notes appears to this effect. According to Dr L, he either wrote to or telephoned the hospital at this time, but there is no independent evidence to suggest that this actually happened.

Mr B saw Dr L on two more occasions within the following seven days. The notes relating to these consultations were extremely brief, recording only repeat prescriptions.

Two days later, Mr B telephoned Dr L’s surgery to say that his anti-migraine treatment was not working. He was told to come in and see Dr L, but in the event did not do so. In fact, he was not seen until three weeks later. Upon visiting him at home, Dr L discovered his patient was extremely unwell, with deep jaundice, vomiting, nausea and fever. Mr B was admitted to hospital, where he was found to have liver failure.

Sadly, his condition then deteriorated due to encephalopathy and he died before a liver transplantation could be carried out. The postmortem examination gave the cause of death as acute hepatic necrosis due to anti-tuberculous chemotherapy.

The particulars of the action brought against Dr L were that he had failed a) to perform a liver function test; b) to warn his patient of the side effects of the drug; and c) to advise him to attend the surgery if he suffered nausea or vomiting.

Expert opinion

We asked two experts for their opinions. Referring to the fact that the telephone call from Mr B did not result in him being seen by Dr L until three weeks later, one expert said: ‘I do not believe that there is any way as a general practitioner he could have been expected to realise that this patient was actually in the early stages of liver failure, but I am afraid he does not appear to have put himself in a position even to re-assess the patient.’

The expert also felt that since Dr L was concerned enough to suggest a referral to hospital after Mr B attended him with haemoptysis, this should have ‘triggered some response’ when it became evident that his patient’s condition had not improved some nine days later.

Recognising that the case would likely be indefensible, we resolved to settle the case.

Learning points

Most doctors would sympathise with Dr L, wondering how he should be expected to keep track of this one patient among many. Should patients be held more accountable for their behaviour? Or does the doctor, as the expert, rightfully bear most of the responsibility? We welcome readers’ views.

There are three things that might have prevented this awful outcome:

  • A practice procedure for expediting and keeping track of urgent referrals.
  • A protocol for chasing up non-attendance by patients.
  • Educating patients about the effects of their medication and the danger signs to watch out for.