Repeated headaches in eight-yearold Master J leads to a missed diagnosis and a claim against Dr P. By Dr Gabrielle Pendlebury, Medicolegal Consultant, and Ceylan Simsek, Case Manager, Medical Protection.
A case from the UK Medical Protection office highlights the role of the medicolegal consultant in assisting when there has been a delay in diagnosis.
Master J, an eight-year-old boy, was referred to the Emergency Department by his GP with a three-month history of headaches. The headaches were occipital and frontal and relieved by paracetamol, and the referral indicated that on examination the optic discs were red with a blurred disc margin.
Dr P examined Master J, noting that the headaches occurred in the mornings and after lunch, with no vomiting. Dr P documented that the pupils were equal and reactive, fundoscopy was normal and no abnormality was detected on examination of the central nervous system. Dr P’s impression was of occipital headaches without vomiting or photophobia.
Dr P discussed the case with the consultant paediatrician, Master J was admitted overnight for observation and Dr P believed that she had asked the consultant to re-examine the optic discs. Dr P’s entry in the medical records following this was: “Discussed with consultant – review – normal discs – observe overnight.”
Master J woke repeatedly in the night complaining of headache, which was relieved with paracetamol. Master J was reviewed by the consultant in the morning and diagnosed with migraine.
Master J was discharged home and advised to stop eating chocolate, cheese, peanuts and monosodium glutamate, with review in clinic in one month. Unfortunately, this appointment was missed as symptoms had improved with the change in diet.
Two months later Master J was again urgently referred to the Emergency Department by his GP due to a very severe headache accompanied by nausea and vomiting. Examination was unremarkable, fundoscopy was normal and the previous diagnosis of migraine was confirmed.
Master J was reviewed by the consultant paediatrician the following week, who noted that Master J was suffering from persistent symptoms of headaches every day and buzzing in the ears. A CT scan was arranged and it revealed a large medulloblastoma. Master J underwent posterior fossa craniotomy for removal of the tumour, which was successful. Master J also underwent a course of radiotherapy.
Four years later, a claim was made
Mrs J pursued a claim against Dr P and the hospital. It was alleged that Dr P had failed to adequately examine the patient and had misdiagnosed migraine. The consultant paediatrician that Dr P had discussed Master J with said that he had not examined the fundi.
Dr P contacted Medical Protection for assistance after being served with the formal letter of claim; the public hospital legal department dealt with the claim but the matter was still passed to a medicolegal consultant to advise.
Dr P was devastated; Master J had been left with some residual disability after the treatment. Dr P found it difficult to come to terms with the possibility that there was a delay in his diagnosis.
The claim against Dr P and the hospital was settled by the hospital, in respect of the three-month delay in diagnosis.
Unfortunately, to err is human. This can be uncomfortable to acknowledge within healthcare, as errors, whether individual or systemic, can lead to patient harm. However, mistakes provide an opportunity to learn, and prevent similar mistakes from happening again. Errors are not marks of indifference or intolerance, but a vital part of how we learn and change. Errors allow us to alter our perspective and understanding of systems and events. A culture that inhibits transparency around errors and mistakes reduces our capacity to learn and improve patient care.
Dr P’s medicolegal consultant at Medical Protection was able to reflect on the care with Dr P and help her identify areas for targeted professional development. Fundoscopy is a difficult skill and given the time elapsed it was impossible to determine if the consultant had viewed the fundi. Continuing professional development therefore not only focused on refreshing clinical skills such as fundoscopy and history taking around headache and raised intracranial pressure, but it also looked at documentation. The entry related to review by the consultant was ambiguous: “Discussed with consultant – review – normal discs – observe overnight.”
This could be interpreted in a number of ways. Dr P changed her practice by making more detailed entries to reduce the risk of multiple interpretations.
Medical Protection was also able to support Dr P by advising her of the process and supporting her with writing a statement. This support was invaluable; Dr P had moved hospitals and did not understand the process; she felt alone and was frightened, so having an allocated medicolegal consultant made the situation understandable and manageable.
In the NZ medicolegal environment there is no financial claim against the doctor or the DHB. However, although the process is different, the medicolegal consultant still has an important role in supporting Dr P. A delay in diagnosis such as this would result in an ACC Treatment Injury claim that provides the compensation to the child and family.
Usually this would be completed by the doctor that ultimately made the correct diagnosis, but the medicolegal consultant would discuss with Dr P so that she ensures that this has been lodged. If ACC consider an event represents a sufficient degree of ‘risk of harm’ to the public, they may refer Dr P to the Medical Council (MCNZ). The MCNZ in turn sometimes investigates and passes it on to the Health and Disability Commissioner (HDC). Medical Protection would assist Dr P in making a response to such investigations.
In addition, the family may complain themselves directly to the HDC, because while ACC provides the financial compensation, a complaint made to the HDC provides accountability. HDC complaints can be very stressful for doctors. The medicolegal consultant would assist Dr P by providing an explanation to her of the HDC process, possible outcomes and timeframes, but also in preparing a report of the care she provided.