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Who’s to blame?

14 September 2014

Mrs B, 40 years old, was referred by her optician to see an ophthalmologist, Mr F, because of concerns about possible raised intraocular pressure and right-sided amblyopia. Mr F confirmed the diagnosis of right-sided amblyopia, found her to have normal intraocular pressure and documented some visual field loss in both eyes, which he considered was performance-related. He advised reassessment in six months but the patient did not attend for follow-up. Mr A attempted to conduct further follow-up consultations on a number of occasions but Mrs B failed to attend.

Ten years later Mrs B was admitted to hospital with smoke inhalation after an accidental house fire. Her only significant past medical history was a hysterectomy for menstrual disturbance some years previously. The medical consultant on call was an endocrinologist, Dr Y, and she was discharged after two days under his care.

A year later she was seen by consultant gastroenterologist, Dr Z, with hepatomegaly due to alcoholic hepatitis. Soon after, Mrs B was admitted under Dr Z’s care after taking an overdose of chlordiazepoxide. A junior doctor commented in the notes that she had “noticed a change in her appearance” that was “interesting, but not classically like acromegaly” and recommended further investigation. Dr Z had no recollection of hearing such comments and no further investigations were carried out.

Over three years later a brain MRI scan was carried out to investigate mild neurological symptoms and memory impairment following a fall. The MRI scan showed an abnormality in the pituitary gland and a subsequent pituitary MRI scan showed a pituitary macroadenoma measuring 1.5cm. Mrs B was found to have a hoarse voice caused by oedematous vocal cords, and a large tongue, nose and hands. Her prolactin level was elevated and a diagnosis of acromegaly was made. Mrs B underwent uncomplicated transphenoidal surgery to remove the pituitary tumour.

Following surgery Mrs B had numerous medical problems caused by late stage acromegaly and other problems related to the hormonal disturbances brought on by removal of the pituitary gland. An MRI scan the following year showed no signs of tumour recurrence.

Mrs B brought a claim against Mr F, Dr Y and Dr Z, alleging that on three occasions opportunities to diagnose her pituitary tumour were missed.

Expert opinion

Most of Mrs B’s medical problems were the direct effect of undiagnosed acromegaly. The acromegaly could also have contributed to depression, consequent alcoholism and memory loss. The menstrual disturbance may have been due to the hyperprolactinaemia. Early diagnosis and treatment would have given Mrs B a substantially better quality of life.

The claimant’s expert considered that Mr F, Dr Y and Dr Z had “missed opportunities” for making the diagnosis. Significantly, a consultant endocrinologist examined Mrs B when she was admitted with smoke inhalation. The expert commented that it is not unreasonable to expect an endocrinologist to detect the clinical signs of acromegaly during a routine clinical examination.

However, experts instructed by MPS were supportive of the care provided by the doctors. The physical changes of acromegaly are slow to develop and the diagnosis is notoriously difficult to make in the early stages. Mrs B’s alcoholism could also have contributed to the changes in her facial appearance, making the acromegalic features more difficult to pick up.

MPS issued a robust defence to the allegations. Eventually, Mrs B discontinued her claim.

1 comment
  • By John SM Leung on 08 February 2015 08:04

    I think we have to define the limitations of a doctor, and make this clear to the patients from the very beginning.

    No doctor is perfect, no matter how experienced and learned; no investigation is fool-proof no matter how sophisticated and expensive. Every doctor must make it clear to each patient that he is not almighty and medical science is not an exact science. If the patient's expectation is limitless and would settle for nothing less than 100% perfection, then the doctor-patient relationship becomes a minefield and it is far safer to have it terminated.

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