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Suffer the little children

01 May 2012

M had always been a rather sickly child who missed a lot of school through minor illness. Her mother brought her to see the GP frequently with her asthma, eczema and possible food intolerances. Most of the entries in her medical records had remarks about her low weight, small size and generally unhealthy appearance. M’s mother would often request home visits and they were regular users of the surgery.

When M was 12 years old she became unwell with a cold. Her mother requested a home visit. This was declined and standard advice for a non-specific viral illness was given. Over the following ten days M’s mother rang the surgery several times to report what appeared to be minor influenza symptoms. She described a mild fever, a runny nose and aching muscles. She spoke to her GP Dr T and several of the other partners who documented this and advised giving paracetamol and plenty of fluids.

M’s mother became increasingly anxious because she felt her daughter was not improving and “just didn’t seem right”. She started to ring the surgery more often. She spoke to different GPs and reported new symptoms of swollen eyes, severe headache and general weakness. She felt frustrated because she had the impression that the GPs were not listening to her concerns. She stated later that the doctor on the other end of the line would keep saying “aha” or “I see” and seem disinterested in her worries.

The GPs asked her to bring M down to the surgery but her mother said she was too ill to leave the house so a home visit was arranged by Dr C. His notes from the visit described M as “looking rather ill, as usual” and the puffy eyes were put down to a flare up of her longstanding eczema. Dr C prescribed some hydrocortisone cream for use around her eyes and advised M to get out of bed and try to get back to normal.

The next day M felt very weak but her mother tried to get her out of bed, like the GP had suggested. She collapsed on the floor and her mother called an ambulance that took her to the emergency department. She was diagnosed with severe bilateral orbital cellulitis and scans showed bilateral cavernous sinus thrombosis. Unfortunately, in spite of aggressive treatment, M became blind.

M’s mum made a claim against all the GPs involved. Experts could not support the GPs’ treatment. The case was settled for a moderate amount.

Learning points

  • Patients who see their doctors with minor ailments all the time may eventually present with a serious complaint. It is important to be mindful of frequent attenders whose serious symptoms can be missed. Extra care should be taken.
  • Repeated calls should be a red flag. They should always make doctors stop and think.
  • Doctors must always be able to justify any decisions they make and have a low threshold for having a face-to-face consultation.
  • Telephone consultations are challenging where it is hard to make a proper assessment of the patient. Effective telephone triage is essential. Listen to a podcast on how to improve your patient triage over the telephone.