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Forgotten blood test results: forgotten patient

07 June 2019

Baby L, a term baby with an unremarkable antenatal history, was brought to Dr W for a hepatitis B vaccination at around four weeks of age. The baby was noted to be mildly jaundiced.

On further questioning, the mother stated that the baby’s stools were pale. Blood tests were taken, including a total bilirubin level and conjugated bilirubin level. Dr W advised the mother that she would be called if the blood test results were abnormal. Unfortunately, following a busy clinic, Dr W misplaced Baby L’s details, so was unable to trace the results.

The results showed a total bilirubin of 110 micromol/l and a conjugated bilirubin of 55 micromol/l. When the results were received at the surgery, Dr W happened to accidentally mark them as normal, so they were automatically filed in Baby L’s record without any further action being undertaken.

One month later, the baby’s mother attended the surgery with her other child and asked about Baby L’s results. The abnormal bilirubin levels from four weeks ago were identified at this point. Bilirubin levels repeated that day showed a total of 124 micromol/l and a conjugated level of 70 micromol/l.

Baby L was urgently referred to the local paediatric department for further assessment and management. He was diagnosed with biliary atresia and underwent a Kasai procedure four days later. The baby was 70 days old at the time. He made an initial good recovery but two months later deteriorated and needed a liver transplant. He remained on immunosuppressants with an optimistic ten-year prognosis.

The parents of Baby L brought a claim against Dr W, alleging a failure to follow up and act on the first set of abnormal bilirubin results, leading to delayed diagnosis and management of biliary atresia. They claimed that as a result of the delay, the Kasai procedure had a suboptimal outcome and so led to the need for a liver transplant.Dr W contacted Medical Protection and requested assistance.

Expert opinion

The expert instructed by Medical Protection opinion was critical of Dr W’s management, citing his loss of the baby’s details, which meant he could not follow up the blood test results – despite the advice he had provided to the mother – and then he signed off an abnormal set of results. These errors led to a delay in diagnosis, which was only circumvented by the mother asking about the results whilst in attendance at the practice for another reason. Expert opinion also said that a full liver panel should have been requested at the time of the original testing.

Expert opinion on causation concluded that the delayed diagnosis did not cause the need for a Kasai procedure, but the consensus was that early surgery (within the first eight weeks of life – some even say the first four weeks) would have led to a better outcome. In addition, they noted that although a Kasai procedure can address biliary atresia in the short term (and eliminate the need for a transplant in up to 25% of patients), by the age of 20, some 70-80% of patients would need a liver transplant regardless. Thus on balance, they concluded that Baby L was more likely than not to have always needed a liver transplant at some point in his life. However, the early failure of the Kasai procedure had expedited this need and prolonged the time he would spend on immunosuppressants.

Outcome

Medical Protection settled the claim for a moderate amount, while continuing to monitor Baby L for an updated prognosis and potential further payments.

In New Zealand we very rarely see claims. In cases such as this, a common avenue for patients is to make a complaint through the Health and Disability Commissioner or the Medical Council of New Zealand (MCNZ). In addition, patients may make a treatment injury application through the Accident Compensation Corporation (ACC). ACC will assess the application, and if they believe that a doctor poses a risk of harm to the public they will make a notification to the MCNZ.

Learning points

  • Clinicians can deal with hundreds of blood test results every day. Having a robust system to manage results is crucial, to ensure that results are dealt with in a timely manner and that patients don’t fall through the cracks.
  • Be careful on reviewing results electronically, in case the wrong button is clicked and they are filed instead of actioned.
  • Patients should be informed about how and when they will be notified about results. This plan should also be documented in the medical records.
  • It is common practice in general practice to only contact the patient if results are abnormal, which is considered acceptable. However, for results that you consider to be very clinically significant, such as in this case, it is advisable to have added layers of safety. You might advise the patient that they will receive the result regardless of it being normal or not; set yourself a tracking task and/or advise the patient to contact the surgery if they have not heard from the practice within a reasonable timeframe.
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