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Falling on deaf ears

01 November 2004

In early 1998, Mr L, aged 29, went to see his GP, Dr G, about his painful and inflamed right ear. He had been dizzy and losing his balance. He had suffered with chronic ear disease for at least 15 years, leaving him deaf on the left side.

He was known to have a right-sided eardrum perforation and cholesteatoma. Mr L used a hearing aid in his right ear. Dr G noted his symptoms, diagnosed otitis externa and prescribed co-amoxiclav, asking Mr L to come back if things didn’t settle.

Two months later, Mr L came to see Dr G about a bad back and continuing ear problems. Dr G kept detailed records about the back problem but recorded only ‘Rt otitis, co-amoxiclav’ with regard to Mr L’s ear. After another fortnight, Mr L saw Dr G again with further ear pain, soreness, dizziness, vertigo and poor balance. The terse record shows ‘Recurrence Rt ear. Swab.’

The next day, Mr L collapsed at work and was taken to A&E. He had severe swelling around the right ear and right side of his neck, had vomited, been febrile and was extremely dizzy. A lumbar puncture proved the diagnosis of bacterial meningitis.

Mr L had a CT scan which showed extensive bony erosion of the mastoid. After antibiotics and extensive surgery to drain a massive mastoid abscess, Mr L made a good recovery but was left totally deaf.

Mr L sued Dr G alleging that he had never examined his ears with an otoscope. Mr L therefore claimed that Dr G had failed to diagnose his severe condition and not referred him to hospital when necessary.

Dr G insisted that he had used an otoscope, and pointed out the difficulties of distinguishing between otitis media and externa in the presence of inflammation and discharge in the ear canal.

Expert opinion

One GP expert accorded with this view. Another GP expert felt that Mr L’s troublesome ENT history, along with the vertigo, should have prompted Dr G to refer Mr L for urgent ENT advice after each consultation. The expert also commented that Dr G hadn’t appeared to appreciate the importance of carefully guarding Mr L’s residual right-sided hearing.

The poor records kept by Dr G made defence of his decisions next to impossible, as he had not documented any otoscopic findings in the consultations. An ENT expert was confident that if Mr L had been referred earlier, surgery would have prevented the onset of meningitis and total deafness.

We settled the case, with a 60% contribution from the hospital, which gave the original ENT care to Mr L, after examination of their historical management revealed significant deficiencies. Mr L received a sum equivalent to £260,000.

Learning points

  • Examination techniques – Without documentation of the clinical techniques used and relevant specific findings, it is impossible to know the truth of the assessment a doctor has made. It becomes one person’s word against the other’s. Since the courts are much more likely to favour patients’ accounts of events, it is very difficult to defend those clinicians whose notes do not include this level of detail.
  • Otitis media – This is a common but occasionally dangerous condition, as this case shows. In the UK, Prodigy’s clinical-governance guidance website gives useful advice for primary care physicians .
  • Pre-existing disability – When treating a patient with impaired function caused by a previous illness, take care that you consider an appropriate threshold for intervention. Complete loss of a sensory modality or body function, due to the compounding of an original injury by new damage, can be devastating. It is also likely to result in a high award if a claim is made.