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Casting stones

01 May 2010

Mrs F was a 28-year-old teacher with two children. She had been fit and healthy for most of her life, but had seen her GP, Dr T, four times in two years with urinary symptoms. At each visit she complained of discomfort passing urine and of needing to pass urine with increased frequency. She had also noted that the urine had a “strong smell”. She had never felt particularly unwell with these symptoms and had not been feverish or suffered with loin problems.

Each time she visited Dr T, he sent an MSU to the laboratory. Two of the MSUs showed a positive bacterial culture and indicated the sensitivities to different antibiotics. Dr T gave appropriate antibiotics to treat her UTIs. On one of the occasions he had given the correct antibiotic empirically while awaiting the result. On the other occasion, he waited for the result, but then gave prompt treatment. Two of the samples showed “no growth” with no pyuria or haematuria, so Dr T did not give antibiotics on those occasions.

Dr T documented that he was considering an IVP after the third infection but as he was about to arrange this Mrs F fell pregnant, so he decided to delay the IVP. Mrs F suffered one more UTI during her pregnancy, which was promptly treated with no adverse effect on the pregnancy, and she delivered a healthy son.

When she saw Dr T for her post-natal check, he arranged an IVP for her.

The IVP showed bilateral staghorn calculi. There was loss of function in the right kidney of 75%. Mrs F underwent a right nephrectomy and had to spend a period of time in hospital recovering. She felt angry that this had not been picked up earlier and felt that an earlier IVP could have saved her from her nephrectomy.

Mrs F made a claim against Dr T for delayed diagnosis of renal calculi. Expert opinion was wholly supportive of the case management and the case was successfully defended.

Learning points

  • Complaints and claims are not always synonymous with bad practice. Patients’ perception of a delayed diagnosis can be wrong.
  • Robust systems can ensure that decisions to defer investigation can be followed up and not lost.
  • This case was defended successfully, based on good documentation and good management by the GP (sending MSUs every time). Taking the time to document not only what happens, but also the planning and follow-up of future management can make a difference.
  • The Health Protection Agency has published a useful reference guide: Diagnosis of UTI – Quick Reference Guide for Primary Care (2009).
  • The Drug and Therapeutic Bulletin published a useful article about imaging in women with UTIs. It states that “any woman who has recurrent, symptomatic and unexplained urinary infections should be referred for investigation using radiological imaging, such as intravenous urography and ultrasonography, to exclude anatomical abnormalities”. Drug and Therapeutic Bulletin (1998), 36(4), 30-2.
  • NICE have published guidelines about UTIs in children: Urinary Tract Infection: Diagnosis, Treatment, and Long-term Management of Urinary Tract Infection in Children (2007). Making the diagnosis is done differently at different ages and the imaging guidelines also vary with age.