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Cooking up trouble

01 September 2007

Mr C was in his early thirties and had had a difficult upbringing, living largely in care homes until the age of 16. For many years he had misused alcohol and drugs and slept rough or at hostels. Lately, he had started to get things together, had moved into a flat of his own and had registered at his local general practice.

Mr C came to see one of the partners, Dr S, who remembered him from his stint in A&E as a junior doctor. Mr C complained of being very tired, sleeping a lot, a hacking cough and chronic nausea with vomiting. He admitted to drinking several litres of strong cider per day, but was adamant that he had used no illegal drugs since finding a place to live. Dr S found no physical signs on examination except a temperature of 38.2°C and scattered wheeze and crackles in his chest. Dr S thought that Mr C had a chest infection and alcohol-induced gastritis. He prescribed amoxicillin and ranitidine and advised Mr C to abstain from or cut down on drinking, and arranged a review in a week’s time. Unfortunately Mr C did not attend.

The next time Mr C came to the practice he saw Dr K. He felt worse and “poorly all the time”, so much so that he had virtually stopped drinking alcohol as it made him feel worse. Dr K checked some screening blood tests which showed a moderately raised gamma-GT and an elevated ESR of 54 mm/hr with a raised CRP of 20 mg/l. Unfortunately, Mr C did not attend his review appointment to discuss his blood tests.

Mr C attended twice more, and missed another three appointments. He had the same complaints, a cough being prominent, for which he was prescribed further courses of amoxicillin, by both Dr K and Dr S. Three months after his first attendance, he was seen in the local A&E department and admitted under the care of a physician. He was found to be suffering from subacute bacterial endocarditis and required prolonged intravenous antibiotic therapy and heart-valve replacement surgery.

Mr C started a legal claim against Drs K and S alleging that they had been negligent in not considering the diagnosis of endocarditis and seeking evidence of it by further investigation or referral.

Expert opinion

An expert in general practice commented that Mr C appeared to be a very difficult person to help at times, and sympathised with the difficulty of assessing illness in someone with a relatively chaotic lifestyle and recurrent non-attendance at appointments.

However, the expert added that Mr C’s continuing and consistent non-specific complaints, in the context of a raised ESR/CRP, and the possibility of previous intravenous drug use, should have prompted a consideration of the diagnosis of bacterial endocarditis.

At the very least, it was felt that the abnormal blood results and chronic complaints should have prompted their repetition and further investigation for a focus of infection or other cause. The expert was critical of the documented extent of physical examination carried out at each visit, pointing out that there was little confirmatory clinical evidence of a chest infection, according to the notes.

An expert in cardiothoracic medicine noted that earlier diagnosis may not have significantly altered the outcome for Mr C, as surgery was likely to have been necessary in what was thought to be a relatively chronic and indolent presentation of subacute bacterial endocarditis.

We defended Drs S and K on the grounds that any alleged deficiency in their approach to the case could not be proved to have caused harm to Mr C, and the claim was eventually discontinued.

Learning points

  • Abnormal investigation results must be acted upon, and either repeated to confirm their relevance, or a cause sought for the derangement.
  • Where a patient’s complaints are prolonged and unchanging and therapy does not appear to be helping, take a step back and ask yourself if there is an alternative explanation for the patient’s symptoms, signs and investigation findings. Seek advice from a specialist if you are unsure.
  • For a negligence claim to succeed, it must be shown that there was a breach of a duty of care to the patient, and that this directly caused the patient harm. A causal link between the doctors' management of Mr C and the damage to his heart could not be established, so we were able to defend the case.
  • It is good practice to have a system in place to track patients who do not attend. This is particularly useful when you have asked patients to come back and see you for review. It will help give you peace of mind, and make sure that patients who need to be seen do not slip through the net.
  • Although it did not appear to be a major issue in this case, take care not to dismiss the complaints of those with mental health/drug-misuse issues or chaotic lifestyles. These factors actually make them more (rather than less) likely to be physically ill.