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Out on a limb

01 November 2005

Mr A, a bricklayer in his forties, became unwell with a bout of vomiting and some chest pain. He went to the emergency department of his local hospital. He was diagnosed as suffering from musculo-skeletal chest pain caused by retching and discharged on diclofenac.

Three days later he asked his GP, Dr J, to visit him at home. Dr J ascertained that there was no history of cough or sputum production and examined Mr A’s chest, finding no relevant signs. Dr J thought that Mr A had a viral respiratory tract infection and gave him general advice.

Five days after this Mr A came to the surgery complaining of pain in his left hip radiating to his foot. He hadn’t injured himself. Dr J did a thorough examination, finding only some pain on active flexion of the hip but a full range of passive movements with normal reflexes and limb tone. There was some slight tenderness over the hip but no erythema or swelling. Dr J prescribed co-codamol analgesia.

A further five days on, Mr A saw another doctor who found severe left hip pain, an inability to bear weight and exquisite tenderness in the left groin. Mr A was sent to hospital where left-sided pneumonia and secondary septic arthritis of the left hip were eventually diagnosed. Mr A received antibiotics, had pus aspirated from the hip and underwent an arthrotomy. He made a good recovery.

When he was reviewed two years after his illness he reported an unlimited exercise tolerance, was not using painkillers and had just completed a long-distance walking holiday in the Welsh mountains. He had some limitation of internal and external rotation but the affected hip was essentially normal when examined.

Shortly after this Mr A made a claim against Dr J, alleging that he had been negligent when assessing Mr A’s chest pain and, subsequently, his hip pain. It was alleged that this negligence had led to ongoing pain and dysfunction in the right hip which prevented Mr A from working.

Expert opinion

GP expert opinion was supportive of Dr J’s clinical approach, note-keeping and decisions. The primary infection had presented quite atypically and several other doctors had found no clinical signs of pneumonia when examining Mr A. The diagnosis of septic arthritis of the hip joint was felt to be sufficiently rare and difficult to detect that Dr J could not be blamed for failing to diagnose it after his thorough assessment.

An orthopaedic expert examined old x-rays that showed Mr A’s hips had significant signs of osteoarthritis predating the septic episode. Additionally, it was thought unlikely that there was established and clinically detectable septic arthritis at the time that Dr J assessed Mr A’s hip, given the timing and progression of the primary infection and his symptoms.

The difficulty of detecting signs of early sepsis in the deeply-buried hip joint was noted. The orthopaedic expert thought it unlikely that Mr A’s ongoing symptoms could be attributed to the septic arthritis and that his reported inability to work was puzzling given the initial good outcome.

We rebutted the claim and were surprised when Mr A and his legal team persisted in the face of these expert opinions. We also obtained some video evidence of Mr A attending a building site wearing a hard hat, which we thought was highly suggestive that he was working regardless of his assertions in the claim. Despite this evidence the claim was taken to court where we successfully defended Dr J and the claim was dismissed.

Learning points

The value of good records

This case shows the value of good quality contemporaneous notes and clear documentation of suspected diagnoses and clinical thought processes. We were able to defend Dr J as it was clear he had made an appropriate and thorough assessment and made sound judgments on the evidence available to him. Where expert opinion supports the actions of a clinician we will defend them.