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Casebook Vol. 20 no. 1 - January 2012

On the case

Dr Rob Hendry, Deputy Medical Director, introduces this issue’s round-up of case reports, which highlight the importance of being aware of distracting symptoms, and being prepared to revisit decisions, when making a diagnosis

In “Too quick to clear the spine” on page 14, the multiple injuries Miss T suffered in a road traffic accident made it difficult to localise the pain to her neck. As a result of the other distracting injuries, A&E consultant Dr W missed the C6 fracture and removed Miss T’s spinal collar. A detailed record of the severity of the accident might have alerted Dr W to the potential for severe spinal injury. In this case, the two junior orthopaedic doctors did not challenge Dr W’s diagnosis that Miss T’s c-spine had been cleared, despite the paraesthesia in all her limbs. Where necessary, previous clinical decisions should be challenged, even those of senior colleagues.

Similarly, you should always be prepared to revisit your own diagnosis, should symptoms persist. Dr G, in “Double problem, double risk” on page 20, was distracted by Mr E’s multiple complaints and did not reconsider his initial diagnosis. The five-month delay in the diagnosis of squamous cell carcinoma of the tonsil meant that the case could not be defended. In “Too many records spoil the notes” on page 15, ophthalmology consultant Dr C failed to diagnose Mr M’s glaucoma, despite there being recurrent abnormalities in his vision and a family history of glaucoma. Listening to the patient is imperative; have an open, unbiased mind at each consultation and consider a second opinion if you are unable to account for a patient’s symptoms or clinical signs. Inaccurate record-keeping and retrospective amendments to the patient’s records made this case indefensible.

Conversely, accurate record-keeping can help to build a successful defence against a claim. We often receive feedback from members asking us to feature more successfully defended case reports; “Right patient, wrong sample” on page 17 and “More than a bruise” on page 18 are such examples. In “More than a bruise”, none of the doctors involved were found to be in breach of their duties, despite Mr U’s sudden and unexpected death. Records clearly showed the careful management of his condition, examination and documentation of symptoms. Had the records not been comprehensive, there could have been reasonable doubt that there were missed symptoms or signs.

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