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A pain in the buttock

01 January 2011

Mr B, a 46-year-old taxi driver, rang the out-of-hours service complaining of pain in the rectum and constipation.

He mentioned that he had had infected piles before and he was prescribed antibiotics for it. The out-of-hours GP, Dr K, was satisfied by the explanation of symptoms over the phone and wrote a prescription for laxatives and antibiotics to be collected by Mr B from a local pharmacy. He advised Mr B to see his GP after the weekend if the symptoms persisted.

Two days later Mr B visited his GP, Dr L, complaining of worsening pain and feeling unwell. He reported profuse sweating and rigors. Mr B had passed a small amount of motion, but was still experiencing rectal pain. Dr L checked Mr B’s temperature and examined the abdomen, chest and ENT, which were all unremarkable. She chose not to undertake a PR as she presumed the out-of-hours service had done so. Dr L diagnosed resolving constipation and coincidental viral infection. She advised Mr B to continue the antibiotics. She thought that the sweating might be a side effect of the Prozac Mr B was also taking and changed his prescription.

Dr L saw Mr B again the following day, this time as a home visit. She did not perform a rectal examination and advised him to continue treatment. As Dr L visited Mr B after evening surgery, she omitted to make an entry in the patient’s notes.

The following evening, Mr B called the out-of-hours service again. A different GP, Dr A, made a home visit and quickly diagnosed a rectal abscess. Admission to hospital was organised and aggressive surgical treatment was required.

Mr B subsequently launched a claim against Dr K and Dr L.

Expert opinion

The defence of the case was complicated by poor notekeeping. The notes of Dr L’s home visit to Mr B, for example, had been written up several days later, after Dr L heard what had happened to Mr B. Notes wherever possible should be contemporaneous; Dr L should have made an entry as soon as possible after seeing Mr B and, if there was a delay, indicated the reasons why it was added later. 

A GP expert was critical of Dr K for not arranging for Mr B to be seen, and of Dr L for her failure to examine Mr B properly. It was advised that a referral for Mr B should have occurred earlier, when treatment would have been less radical.

The claim was settled for a substantial sum.

Learning points

  • Be aware of the risks of telephone consultations and prescribing. Are you putting yourself in a position to make a sound clinical judgment before offering advice? If you are unable to do this, you should arrange for the patient to be seen. See Your Practice (Autumn 2009) “Do’s and don’ts of telephone conversations”.
  • The interface between out-of-hours care and routine GP care requires careful management to ensure safe handover.
  • Always review documentation and, if unclear, clarify with the patient.
  • Good documentation is essential to safeguard your practice.
  • Giving antibiotics without clinical indications and examination is likely to be indefensible.
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