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The danger of the casual aside

01 May 2008

Mr J, a 28-year-old teacher, called his local out-of-hours service one evening complaining of vomiting and diarrhoea, some abdominal pain and dysuria. He said that he had just returned from the cinema with his wife and the symptoms had come on during the film. He had no relevant past medical history and was on no other medications. The vomiting was getting worse and he was unable to attend the centre, so a visit was arranged and Dr A called to see him at home that night.

Dr A examined him. Mr J was afebrile, had a soft abdomen with suprapubic tenderness but no signs of guarding or rebound. There was 2+ of leucocytes and protein on dipsticking his urine and he made a provisional diagnosis of a urinary tract infection. He prescribed a course of antibiotics with simple analgesia, recommending that Mr J should see his own GP if things did not improve. There was no record of any time frame within which this should happen.

Mr J’s own GP, Dr C, was in the middle of a busy afternoon surgery two days later. Mr J’s wife was attending a routine appointment with him to get a repeat prescription for oral contraception and an assessment of her chronic eczema. She made no mention of her husband’s problems until the end of the consultation, when she stood up and handed over the record of Mr J’s out-ofhours contact. At this point Mrs J claimed that she informed Dr C that her husband still did not feel any better and in fact she was now frightened that he might have appendicitis. She reports that during the exchange that followed Dr C advised her to “give the tablets time to work”. Dr C, however, made no record of this conversation and had no memory of Mrs J giving such detailed information, or indeed that she was so concerned about her husband’s condition.

Mr J’s pain and general symptoms persisted. He did not try to contact Dr C or his own surgery during this time, but two more days later he contacted the out-of-hours service once again, requesting a home visit. A different doctor, who called on this occasion, assessed him and, based on his findings and the history, made a diagnosis of perforated appendicitis and peritonitis, admitting him to hospital as an emergency.

Mr J subsequently lodged a claim against Dr C.

Expert opinion

There was no record made of the conversation between Dr C and Mrs J at the surgery.

Expert GP opinion advised that if Mrs J had mentioned to Dr C that she thought her husband may be suffering from appendicitis, then Dr C should at least have obtained further information about the case and additionally offered a consultation on that day. However, as Dr C recalled the conversation with Mrs J, namely a brief mention on her departure about an out-ofhours visit with no specific voicing of her concerns, or that her husband was still unwell, then the experts thought his actions were reasonable.

MPS defended the case to trial. The court found in favour of Mr J and awarded moderate damages.

Learning points

  • The “casual aside”, often thrown in at the end of a consultation and not always at a convenient moment, has the potential to cause problems. An exhaustive history is not expected, but safety-netting is essential and should help to protect the patient and the doctor involved.
  • When a patient mentions a medical problem to you, you have a duty to deal with it, but not necessarily there and then.
  • A short note of Mrs J's comment might well have resolved this issue more quickly. Relying on one's recollection is often hazardous. Courts have to resolve a conflict of evidence and may prefer the recollection of a patient, for whom this was a unique experience, to that of a doctor, for whom this was one in a series of consultations.
  • The courts make no allowances for the circumstances of a consultation, eg, in this case, where the surgery was very busy.