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Casebook Vol. 22 no. 3 -
September 2014

From the case files...

Mark DinwoodieThis edition Dr Mark Dinwoodie, head of member education at MPS, assesses the key learning from the latest collection of case reports

I’m delighted to have the opportunity to reflect on the cases in this edition of Casebook from an educational and risk management perspective. The cases of Mr D, with his osteoarthritic knees (“A pain in the knee”), and Mrs H, with her neuropraxia following cannula insertion (“A cannula complication”), remind us how record-keeping can contribute to an effective defence against allegations of negligence. Of course, good documentation is also increasingly essential to support good clinical care and enable continuity to be delivered by an increasing range and number of involved healthcare professionals.

It is important that not only should the clinical assessment and any procedure be adequately documented, but also the discussion behind any decision made regarding treatment. It is, of course, a matter of judgment regarding how much to write in the notes and, inevitably, time pressures will contribute to that consideration.

There can be a temptation when a patient returns with no improvement to keep adjusting the treatment, whereas sometimes what is needed is a review of the original diagnosis and adjustment of the treatment to match the reviewed diagnosis

The elusive diagnosis” for Mr M turned out to be diabetes in a patient who had repeatedly attended the GP surgery for several infections. While MPS successfully defended this case, it reminds us of the importance of reconsidering the diagnosis in patients who represent with recurring symptoms or signs. There can be a temptation when a patient returns with no improvement to keep adjusting the treatment, whereas sometimes what is needed is a review of the original diagnosis and adjustment of the treatment to match the reviewed diagnosis.

The system errors of Mrs Y and the blood transfusion (“Transfusion confusion”) highlight the importance of someone taking responsibility when the patient has suffered an adverse outcome and, following an apology, having an open and honest discussion with the patient, explaining what has happened. It is always appropriate to say that you are sorry for what the patient has experienced. It also shows how patients themselves can make a valuable contribution to patient safety.

I hope that you find reading the cases to be interesting and informative. Our range of education risk management products can help you address some of these challenges, and I encourage you to go to the Education & Events section of our site for more information.

Casebook aims to promote safer practice by sharing experiences that we hope you will find helpful. MPS publishes medicolegal reports as an educational aid to MPS members and as a risk management tool.

The case reports are based on MPS experience from around the world and are anonymised to preserve the confidentiality of those involved.

The cases described are historic and the expert opinions that follow in specific cases reflect accepted practice at the time. The learning points are applicable today.

If you would like to comment on a case, please email

The elusive diagnosis

Sep 14, 2014, 09:23 AM
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  • By hari Singh on 04 March 2015 10:53

    The patient presented with rash on penis is suspicious of diabetes. Blood test would have confirmed the diabetes.

    This was missed an opportunity.  

    Dr Hari Singh
  • By Dr Bhate on 04 March 2015 04:29

    Good case review since this is a very common scenario and routine screening tests e g BT, HbA1C are not dealt in emergency appointments, but should have done especially with penile rash etc. However commenting retrospectively on management is always easy.

  • By Dr S .Roy on 26 February 2015 03:26
    Good learning point. Missed opportunity to diagnose Diabetes.

    Dr Roy
  • By Andrew Allen on 26 February 2015 02:44
    Nope - not a 'frequent' attender. Not particularly old. Recurrent genital infection-investigate, a one off, I would not. Not sure there are many learning points here, especially as it never got to judgement. What I have learned, though, is that to avoid litigation I need to investigate 50 year olds with minor infections as if they are going to have a stroke! That's a lot of work.
  • By Martin Stagles on 26 February 2015 11:23

    On the other hand, Mr M's attendances were not all that frequent ....  The story spans almost 3 years, so maybe a routine blood pressure check might have been suggested by the computer notes during that period. 

    But I guess I would have fallen for it as well.

  • By Dr T T Lwin on 25 February 2015 05:00  
  • By Dr Yarra on 25 February 2015 04:57
    Presenting with Penile rash (thrush) was an opportunity to suspect Diabetes in this patient and possibly have checked at least urine and arranged at least for a blood test later, it was possible that was missed opportunity to diagnose Type 2 Diabetes I think.
  • By Dr.Raj on 25 February 2015 01:39  
    Good learning point for all the GPs. Also we should use Pendelton's consultation model ICE.
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