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Initial management of an itchy skin rash

23 October 2018

CLAIM

A middle-aged woman, Mrs Y, presented to GP Dr U with a ten-day history of an itchy rash over her arms and chest, which was forming blisters. The distribution of the rash was on sun-exposed areas of skin, and the blisters were not forming scabs. Mrs Y felt the rash started after she took buscopan.

She had had chickenpox in the past. Dr U considered dermatitis herpetiformis, and arranged blood tests including full blood count, erythrocyte sedimentation rate, thyroid tests and a coeliac screen. All blood tests were normal, and the patient was given reassurance and advice.

At review with a different GP two weeks later, the rash was subsiding, but was leaving areas with a bruised appearance, which the patient was concerned about. A routine dermatology referral was planned, but unfortunately was not made for eight weeks, due to the referral task being closed in error before the referral was made.

In the dermatology clinic a few months on, the skin changes were thought to be post-inflammatory pigmentation. Mrs Y was reassured that the appearance of the patches should settle over the following months, and she was prescribed mometasone cream to assist. Unfortunately, the mometasone was not effective, and Mrs Y was referred for camouflage cosmetics to disguise them.

Mrs Y made a claim against Dr U.

Summary of allegations

It was alleged by Mrs Y’s solicitors that Dr U ought to have prescribed a “strong steroid cream” at the initial appointment and also made a referral to dermatology at that point.

It was alleged that had she done so, the rash would have settled sooner and the skin pigmentation requiring camouflage make up would not have occurred.

Expert opinion

Medical Protection did not obtain an opinion from a GP expert, being confident in basing our letter of response denying breach of duty on the facts of Dr U’s reasonable management at the initial consultation. As we denied breach of duty, it followed that no legal causation flowed.

The claim was not pursued against Dr U following our letter of response denying liability. A co-defendant’s medical defence organisation went on to settle the claim in full on behalf of their member, who had mistakenly completed the dermatology referral task without making a dermatology referral.

Learning points

In primary care, when a claim involves an administrative error, such as a delayed referral, if the individual responsible is not identifiable, then the claim falls to the responsibility of the practice partners. In this case, however, the practice was able to provide Medical Protection with an audit trail showing which staff member had marked the dermatology referral task ‘complete’ in error. It was therefore possible for Medical Protection to relay this audit information to the relevant individual’s legal representatives to encourage them to settle the claim without involving the practice partners.

At Medical Protection we will ask members for their comments on the events in question when we are investigating a claim and preparing our response. In this case, we worked closely with the member to advance a robust letter of response, setting out her reasonable management at the consultation in question.

Blistering rashes can have many causes, including sunburn, extremes of cold or heat, friction, viruses (eg chickenpox, shingles, herpes simplex), chemical irritants, dermatitis herpetiformis, pemphigus, pompholyx, insect bites, and skin infections such as folliculitis. The precise diagnosis may not be obvious, especially early in the clinical course. 

The reasonable management in this case started with simple reassurance and advice, followed by blood investigations, and later a dermatology referral when patient concerns persisted.

NZ commentary

If this complaint went to the Health and Disability Commissioner (HDC), both the initial consultation and the delay in referral would be looked into. Provided the notes were adequate, then the management at the initial consult would likely be judged acceptable. Dermatitis herpetiformis is a rare condition and diagnosis is usually made on skin biopsy.

The delay in referral would be likely to receive an adverse comment. The individual responsible for ‘completing’ the referral task would have primary responsibility for their actions. The practice might also be vicariously liable if there were no policies in place for managing tasks such as this. Evaluation of the relevant systems is an important consideration in the assessment of any incident like this. If the clinical issue involved cancer or other serious health problem, then the HDC would be likely to view the delay with more concern. There would also be the possibility of ACC involvement with a treatment injury claim for failure to provide treatment in a timely manner (in this case referral would be part of ‘treatment’).

There would of course be no financial claim on the doctors involved with this scenario in New Zealand.

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