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Shouldering responsibility

01 August 2003

Mr W was a young dad with a wife and two small children. He developed pain in his neck and right shoulder and consulted his GP, Dr J. Finding some slight tenderness over the right shoulder with a full range of movement, Dr J prescribed ibuprofen.

Mr W attended the practice on many occasions over the next year, chiefly with right-shoulder pain, but also with episodes of back and neck pain. He saw other members of the practice, and the working diagnosis seems to have been muscular pain or ‘mechanical backache’. He received a variety of topical and systemic NSAID preparations, but without any discernible benefit.

At one point he saw a locum who requested an x-ray of his shoulders, which was reported as normal. Mr W remained troubled by his symptoms and saw Dr J at least once a month over the next six months.

By now the pain was affecting his left shoulder and he was experiencing pins and needles in his left arm. Dr J referred Mr W for physiotherapy. Two months of heat, mobilisation and ultrasound resulted in only a slight improvement in joint mobility and pain relief.

Dr J referred Mr W to a local orthopaedic surgeon, Mr O, for advice.

Mr O noted a history of right-shoulder pain, on and off for two years, and found some local tenderness over the right acromion. A repeat x-ray showed a lytic lesion within the right acromion. Mr O compared this to the old x-ray and noticed that it had been present all along, despite the x-ray being reported as normal. Mr O arranged a non-urgent CT scan of the thorax.

Unfortunately, about six weeks after seeing Mr O, Mr W developed paraplegia and was admitted to hospital for urgent investigation. It transpired that he had compression of his thoracic spinal cord, due to multiple myeloma.

Mr W had surgical debulking and received chemotherapy. He recovered from the paraplegia but was left with some neurological disability. His myeloma recurred and he eventually needed an allogeneic bone-marrow transplant.

An action was launched against Dr J, alleging that his delay in referring Mr W to hospital had been negligent.

Expert opinion

GP experts criticised him for persisting with ineffective medication and physiotherapy without seeking an alternative diagnosis. They accepted, however, that he had been misled by the normal x-ray report, which had made his job more difficult.

We sought advice from a radiologist. This proved to be critical of the diagnostic radiologist who failed to notice the lesion in the acromion. Orthopaedic experts were also critical of Mr O. His decision to order non-urgent investigations compounded the delay. They thought that he should, at the least, have arranged for baseline bloods and an urgent bone scan.

He might also have usefully arranged for a radiologically guided biopsy of the lesion to establish a histological diagnosis. According to an expert in haemotology, if this had been done, and treatment initiated immediately, it was likely that Mr W would never have developed paraplegia and its sequelae.

We contributed a small sum on behalf of Dr J to settle this action. The hospital responsible for the x-rays and the orthopaedic consultation paid the remainder of a substantial settlement.