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Arterial embolism

01 August 2005

Among the patients of Dr T and Dr U was a sixty-year-old man, Mr J, who was a heavy smoker. He first saw Dr T to complain of body aches and sickness. The examination proved unremarkable and, suspecting a viral infection, Dr T prescribed domperidone.

Five days later, Mr J was visited at home by Dr U. He described chest aches and pain, and on examination the liver appeared to be enlarged. Trimethoprim and an alginate barrier antacid were prescribed for the suspected chest infection. Dr U also ordered a chest x-ray, which was carried out immediately and revealed a large area of consolidation in the right upper lobe and apex. Ciprofloxacin was prescribed in place of the trimethoprim.

On the next occasion, two days later, Mr J was seen by a deputising doctor after complaining of pain in the leg and the foot. On examination, straight leg raising was restricted to 80 degrees on the right. Although the leg looked blue, a pulse was felt in the foot. A diagnosis of sciatica was made by the doctor, who prescribed an NSAID gel and coproxamol.

According to Dr T’s notes, Mr J consulted him again three days afterwards, and co-codamol was prescribed for his leg pains.

The following day, Dr T visited Mr J at home. He discovered a cold, pulseless right foot and arranged for immediate admission to a surgical unit. The arteriogram showed an occlusion of the superficial femoral artery just beyond its origin, with no vessel filling below the knee.

An endarterectomy and femoropopliteal bypass were tried without success, leaving the surgical team with little choice but to perform an above-knee amputation.

It was alleged by Mr J’s representatives that Dr T and Dr U had failed to examine the foot or to check the pulse or reflexes, thus failing to diagnose ischaemia and incipient gangrene.

Expert opinion

We asked two experts to review the case. Their opinion was that the standard of care provided by the two doctors had not fallen below that expected of a competent medical practitioner. Both felt that the severe pain in the patient’s leg and foot had most likely occurred after Dr U had visited the patient at home.

One expert stated his belief that the arterial embolism had developed either on the day of his admission to hospital or during the day preceding it. ‘This may have been occasioned by his concurrent pneumonia but could not have been diagnosed significantly earlier than it was.

‘In my opinion, the doctors concerned took all necessary and appropriate steps that would have been taken by any competent general practitioner.’

It was resolved to defend the case. When it reached trial, it soon became clear that the strength of the defence, including the high standard of the clinical notes, would prove decisive in countering the allegation of negligence. The prosecution discontinued the case, and an order for costs was made against Mr J.