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Did patient's youth lead doctor astray?

01 May 2004

Following an appendicectomy Ms J, a 23-year-old single mother, consulted her GP, Dr R. She’d suffered abdominal pain and nausea and Dr J treated her with ranitidine, suspecting ‘over acidity’.

Just over a week later, the blood transfusion service notified Dr R that they had found Ms J to be anaemic when she came to donate blood. Her Hb was 9.1 g/dl. Dr R prescribed iron-replacement therapy, but did not investigate the cause of the anaemia.

Miss J’s intermittent lower abdominal pain and nausea persisted, and she visited Dr R once again about a week after he had received the report of her anaemia. This time, Dr R diagnosed irritable bowel syndrome, for which he prescribed mebeverine. At a follow-up appointment, the abdominal pain seemed to be under control and Ms J’s Hb had risen to 11.4 g/dl.

The abdominal pain returned two months later. However, Dr R now attributed this to a side effect of the iron-replacement therapy, which was discontinued.

Over the following 14 months Ms J consulted Dr R on several occasions for various minor problems. There is no mention in the records of any complaints of abdominal pain, nor of monitoring haemoglobin levels. The blood transfusion service then wrote to Dr R again; this time, Ms J’s Hb was 7.4 g/dl. A prescription for ferrous sulphate was issued a month later, when Ms J again attended with bowel problems.

A further six months passed, during which Ms J was a fairly regular attendee at the surgery. She reported continued lower abdominal symptoms, which were treated with prescriptions for an anti-spasmodic, and (later) weight loss.

Eventually she saw another doctor at the same practice who was suspicious of the abdominal pain, weight loss and unexplained anaemia and found a possible mass on abdominal palpation. Repeat Hb was 6.4g/dl and Ms J was admitted to hospital for investigation. Initially, the clinical impression was of Crohn’s disease, but advanced adenocarcinoma of the caecum with metastatic spread was discovered at laparotomy. Ms J died six months later.

A claim was brought, on behalf of Ms J’s young child, alleging that Dr R had been negligent – and that this negligence had brought about Ms J’s untimely death.

Expert opinion

The claim was indefensible because the cause of Ms J’s anaemia should have been explored and the diagnosis of irritable bowel syndrome should have been considered unconfirmed until the cause of the anaemia had been discovered.

On causation, there was a good chance that a curative surgical resection could have been carried out if Ms J had been referred for a surgical opinion when her anaemia and abdominal symptoms first came to light.

We settled the claim for £125,000 plus costs. The sum was unusually large because it was necessary to compensate Ms J’s son for loss of his mother’s care and support.

Learning points

  • Colonic malignancy is uncommon in young people, but it does occur. Beware of attributing symptoms to a trivial cause if those same symptoms would have been worthy of further investigation had the patient been older. When investigation findings point to a probable organic abnormality, further investigations will be necessary. 
  • Iron-deficiency anaemia should always be looked into with a dietary and symptom history and careful examination. If there is no obvious cause for the anaemia, investigate occult sources of bleeding or causes of malabsorption.
  • The British Society of Gastroenterology issued guidelines in 2000 on the management of iron-deficiency anaemia. These set out the range of diagnoses to consider and include handy treatment algorithms. View them at www.bsg.org.uk, in the ‘clinical practice’ section.