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Failure to diagnose pneumonia

01 February 2006

Mr W, a 28-year-old labourer, contacted his GP, Dr Y, for a home visit. He had been feeling generally unwell for a week with flu-like symptoms and difficulty breathing. He was a smoker, but had previously been well and had no significant medical history.

Dr Y diagnosed a viral upper respiratory tract infection and advised bed rest, fluids, cough linctus and paracetamol if his temperature became raised. As there were no lower respiratory signs or respiratory compromise, he did not prescribe antibiotics.

Two days later, the patient telephoned the practice again and spoke with another GP, Dr X. His condition had not improved and he had started sweating profusely. At this time, there was no shortness of breath or any other significant symptoms. Dr X suggested regular paracetamol and arranged to speak with Mr W later the same day to assess his progress.

When they talked again the patient had deteriorated. Dr X made a home visit that evening and undertook a full examination of Mr W, finding evidence of ‘post-flu, right-sided chest infection’. It was specifically noted that Mr W had no signs or symptoms of pneumonia or any other condition that would warrant hospital admission for treatment. Cefalexin was prescribed and a follow-up review with his own GP was advised.

Dr Z, another partner at the practice, was called to the patient’s house the next morning. Mr W had been found dead by his wife at 11.00am and by the time the GP arrived rigor mortis had set in. Mrs W informed the GP that overnight there had been no real change in his condition.

That morning he had gone to sleep on the sofa and she had later found him dead. He had taken only one dose of the antibiotics the previous evening.

Understandably the patient’s family were extremely upset and shocked that the patient had died, especially as he was young and previously healthy. The family wanted to sue the GPs on several grounds.

Firstly, they argued that on the initial visit there was failure to diagnose a lower respiratory tract infection, failure to prescribe antibiotics and order an urgent chest X-ray. At the second visit, they alleged a failure to diagnose the development of pneumonia and to make arrangements for hospital admission.

Essentially, had the GPs failed to assess and treat the patient adequately leading to his untimely death?

Expert opinion

Our experts agreed that initially there were no clinical signs suggestive of pneumonia, Mr W’s chest was clear and the British Thoracic Society’s guidelines state that coryzal symptoms are of negative predictive value for a community-acquired pneumonia. There was certainly nothing to indicate a need for antibiotics in a viral illness or an X-ray.

When Dr X spoke with the patient on the phone, the clinical picture still fitted that of a viral illness. However, he was extremely conscientious in following up Mr W’s phone call and appropriately decided to make a further home visit as new symptoms had developed.

Dr X’s notes of the visit were found to be neat, detailed and meticulous. He had specifically excluded all of the signs that would indicate a poor prognosis and subsequent need for hospital admission. The most important clinical features, which might indicate the presence of severe illness are: new mental confusion, an increased respiratory rate and a low blood pressure (systolic less than 90 mmHg).

Mr W was appropriately prescribed antibiotics but unfortunately died the next day. The course of the patient’s illness after the GP’s visit and the post-mortem findings demonstrate that he had an unpredictably rapid progression of his pneumonia with sudden development of adult respiratory distress syndrome, which is more commonly associated with a viral pneumonia in which antibiotics are ineffective.

The claimant’s solicitors put in a claim for £15,000. They alleged that IV antibiotics, fluid replacement and hospital admission would have prevented Mr W’s death and, on the balance of probabilities, he would have made a full recovery.

After close examination of the case, our experts found that the GPs involved in Mr W’s care had acted with due care and attention and to a standard that would be considered acceptable to a representative body of medical opinion. The doctors’ thorough notes helped show that the management of the patient in the practice and at home was appropriate.

The claim was ultimately rejected.

Learning points

  • Note-keeping is an essential element of tracking a patient’s progress and demonstrating good medical practice. Ruling out significant negatives is as important as recording all the positive findings.
  • It is entirely possible that a patient can fail to display signs of pneumonia, start antibiotics and then die the following day because of the effects of pneumonia. Similarly, a viral infection that progresses quickly into a bacterial one can be lethal.
  • The British Thoracic Society has published Guidelines for the Management of Community Acquired Pneumonia in Adults; these were last updated in 2004. See Notekeeping is essential for demonstrating good medical practice.