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Deficient investigation of iron deficiency

01 November 2003

Mr B, a retired plumber, went to see his GP, Dr J. His cousin had been diagnosed as suffering from a rare, inherited haematological condition and he wanted to know if he had it too. As part of the work-up, Dr J requested a full blood count (FBC) and serum ferritin.

The tests showed that Mr B hadn’t inherited the condition, but revealed borderline anaemia, with a significantly low serum ferritin. The anaemia was not investigated, nor were arrangements made to follow it up.

Six months later, Mr B had a private medical-screening examination. A further FBC showed persistent anaemia. A faecal occult blood (FOB) test was ‘strongly positive’. This information was forwarded to Dr J. She repeated the FBC and haematinics, finding Hb just inside the normal range. Serum ferritin remained grossly depleted. Dr J suspected this was due to a bleeding intestinal polyp and initiated no further investigation.

Two months passed and Mr B saw Dr J again, complaining of epigastric pain, which Dr J attributed to ‘dyspepsia due to stress’.
Mr B’s pain persisted and he saw another partner, Dr E, who documented that Mr B’s bowel habit wasn’t altered. An abdominal examination was recorded as normal. No rectal examination was performed.

Three months after this, Mr B suffered constipation and requested a laxative. A prescription was issued and he was asked to attend the surgery. He saw a locum doctor who, noting a five-month history of abdominal pain and the previous positive FOBs and anaemia, requested an urgent surgical outpatient opinion.

Before he was seen, Mr B was admitted to hospital as an emergency, with intestinal obstruction. He was found to have a large, stenosing sigmoid-colon adenocarcinoma which had metastasised to his liver.

He died within a year of being diagnosed.

Legal action, alleging negligent investigation of Mr B’s test results and clinical complaints by Drs J and E, was brought by Mr B’s family.

Expert opinion

Expert GP opinion was critical of Dr J, ‘The correct response to the blood test results was … to carry out a detailed history in regard to diet and gastrointestinal complaints, conduct an examination and almost certainly to consider bowel investigation.’ This was even clearer when the FOBs became available. Dr E’s failure to relate the abdominal pain to the previous laboratory findings was similarly criticised.

Surgical opinion was that had Mr B been diagnosed when he was found to be anaemic, his chances of survival would have been greater, as metastasis was unlikely to have occurred at this stage. We settled the case for a significant sum.

Further reading

Unexplained iron-deficiency anaemia requires investigation. The British Society of Gastroenterology has published guidelines on the management of iron-deficiency anaemia, which can be found here on their website, www.bsg.org.uk.

A PDF document of the Department of Health publication, Referral Guidelines for Suspected Cancer can be found here on the NICE website, www.nice.org.uk.

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