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Does my patient need to know?

19 July 2018
By Dr Andrew Stacey, Medical Protection medical adviser

Mr K, 28 years old, dislocated his right shoulder when he fell off his motocross bike. He presented to the Emergency Department (ED), where he was seen by the triage nurse and an x-ray was arranged.

The x-ray showed that the shoulder was dislocated, and Mr K was then seen by a clinical nurse specialist (CNS) who, after several unsuccessful attempts, requested that ED consultant Dr U provide procedural sedation so that the shoulder could be reduced.

The CNS ordered a post-reduction x-ray, which confirmed that the relocation had been successful. Mr K’s discharge summary stated: “Discharge Plan/Advice: Follow up with [general practitioner] GP…”

The day following Mr K’s discharge, the x-rays were reported on formally. The pre-reduction report stated: “…There is a 1 X 0.2mm bone fragment posterior to the humeral head…Summary: Anterior fracture…”

The post-reduction report stated: “…Discrete humeral head fracture is not identified, though subtle Hill-Sachs deformity is not easily excluded on this exam. I also question subtle bony deformity of the scapula inferior to the glenoid…if indicated this are can be better evaluated by CT.” That same consultant viewed and signed those x-ray reports and did not feel that any further action was required.

Three days later, Mr K attended his GP practice because of ongoing shoulder pains. Neither the x-ray report nor the discharge summary were available to that doctor at the time. He was referred to see an orthopaedic surgeon, whom he saw some five weeks later.

Mr K subsequently made a complaint to the HDC: in part, that the orthopaedic surgeon had diagnosed him with a fracture (a Bankart lesion) and advised him that this should have been addressed “right away”. Mr K had a series of clinic appointments and further investigations, and was considered for surgery to repair his torn rotator cuff. However, surgery was not performed owing to a lack of movement in his shoulder. Mr K told the HDC that he was now faced with a permanent disability due to a severe lack of movement in his shoulder. The HDC opened an investigation.

The investigation

Dr U advised the HDC that he did not feel that the abnormality as described in the x-ray report required him to take any further immediate action, and he was reassured by the knowledge that Mr K would be following up with his GP, as recorded in the notes. He further advised that, routinely, all x-ray reports were sent to the patient’s GP. The HDC noted, however, that on Mr K’s report the GP was listed as “Dr A unknown” and the reports were not sent to his GP.

While Dr U acknowledged that there would be occasions where recognition of an abnormality required notifying a patient of the abnormal result, provision of the report, and ensuring that appropriate follow-up had been arranged, he did not feel that this was one of these cases. Further support came from a senior orthopaedic surgeon, who advised in an email to Dr U that: “[T]he radiology report suggests a tiny avulsion fracture and I don’t feel there would be any need to inform a patient of that. They are quite common and often not even spotted…I don’t think there was anything wrong with the way this was handled.”

The DHB advised the HDC that Mr K would have been advised to take a copy of his notes and x-ray to his GP, but the HDC noted that he didn’t recall this. The DHB also stated that while it did not view the fracture as a clinically significant bone deformity, it did accept that it was good practice to communicate this to the patient.

Expert opinion

The HDC obtained expert opinion from an ED specialist, who felt that it was a major departure from the expected standard of care that the abnormalities documented by the reporting radiologist were not passed on to the patient or the patient’s GP. The expert felt that because the ED did not have the patient’s GP’s details, Mr K should have been contacted to inform him of the findings, and either he or his GP be provided with a copy of the report so that appropriate and timely follow-up could be arranged.

The HDC acknowledged Dr U’s opinion that the abnormality identified in the x-ray report was not one that required reporting to the patient or his GP, and that the end process would have been the same even if the information had been provided. However, in the HDC’s view, even though the abnormality was small, Mr K had the right to receive available information in relation to it.

The HDC made reference to Right 6(1)(f) of the Code of Rights, which states: “Every consumer has the right to the information that a reasonable consumer, in that consumer’s circumstances, would expect to receive…” This included the results of tests, and the HDC was critical that Dr U did not inform Mr K of the abnormality seen on the x-ray, especially in light of the fact that the x-ray reports were not copied to Mr K’s GP.

Outcome

The HDC found Dr U in breach of Right 6(1)(f) of the Code and recommended that he apologise to Mr K for the failings that had been identified.

The HDC also found the DHB in breach for not providing Mr K with reasonable skill and care (Right 4(1) of the Code); in part for not capturing his GP details on their system. The HDC acknowledged changes the DHB had made, including the development of a letter to be sent to all patients with a condition or injury identified on an x-ray report that was not seen at the time of their presentation. This was to be used when the injury/condition was of a nature that did not require the patient to be recalled to the department, but would advise the patient to discuss the problem with their GP. It was recommended that the DHB also apologised for its failings and report back to the HDC with evidence that this new letter was being used in practice.

The HDC advised the Medical Council of Dr U’s name and the outcome of their investigation. The Medical Council was reassured by the changes he had made to his practice and did not feel that any further action was required.

Learning points
  • The information that a “reasonable consumer, in that consumer’s circumstances, would expect to receive” is always going to be a very subjective test. Based on this decision, the HDC appears to have a very low threshold and practitioners should be in the habit of advising patients of all abnormal test results, irrespective of how abnormal or clinically significant they may be.
  • Systems and processes can be developed to facilitate this (such as the letter devised by the ED department in this case).

  • Organisations should ensure that systems are in place for capturing patients’ GP details and populating these on all correspondence to ensure continuity of care.
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