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Hard to stomach

01 January 2008

Ms Y, a 28-year-old mother-of-three, registered as a new patient at a busy urban practice in a socially deprived suburb. She had just moved to the city, but provided no details of her previous GP. It was not possible to trace her old medical records on the basis of the information that she supplied.

Over the course of six years she attended the practice many times due to a range of concerns over her own health, including gastrointestinal symptoms, and her children’s, one of whom suffered from cystic fibrosis. She lived in social housing and often appeared to be in dispute with her local housing office over the quality of her accommodation. Three members of the practice had written letters on her behalf, detailing how Ms Y’s health, and that of her children, impacted upon her housing needs. Her father had died aged 42, from gastric carcinoma.

She saw 12 doctors at the practice over this time, who prescribed triple therapy for eradication of H. Pylori four times, on the basis of upper gastrointestinal endoscopy and serology results. This seemed to have little effect on her symptoms, but two doctors recorded that they were unsure of her compliance with the regimen. Ms Y frequently failed to attend consultations and blood test appointments.

She was referred to local secondary care services 12 times and attended six of her appointments. Half of these were to investigate complaints of upper gastrointestinal disturbance, predominantly presenting as bouts of severe heartburn and nausea. Other problems included abnormal cervical smears requiring colposcopy, and paroxysmal weakness in her left leg.

Subsequently she developed weight loss and melaena, being referred urgently to the gastroenterology service. Carcinoma of the body of the stomach was diagnosed. She died eight months later. Her family started a legal claim naming all the partners at her practice, alleging negligence in assessment and delay in referral of her gastrointestinal complaints.

Expert opinion

A GP expert exhaustively examined the course of events as recorded in the notes, concluding that the partners at her practice had behaved competently throughout. They had kept good records and correctly picked up on relevant problems, even where Ms Y’s patchy attendance had made the issue difficult. It was felt that she had been properly assessed and referred at all significant points in her various presentations. Once her legal team were aware of this opinion, the claim was discontinued on their advice.

Learning points

  • When dealing with a patient with many problems and a challenging approach to keeping appointments, a regular review of all problems, be they active, inactive or unaddressed due to non-attendance, is very useful and prevents such people from “slipping through the net”.
  • Despite the complexity of Ms Y’s problems and the chain of events surrounding them, the high quality of record keeping in this instance made the case relatively easy to defend.
  • In the UK, the following guidance from NICE is pertinent to this case: Managing Dyspepsia in Adults in Primary Care
  • Many members of the practice were involved in this case. Your membership of MPS entitles you to seek indemnity only in relation to your own acts and omissions. Your subscription is set at a level that reflects this “personal” risk. If you employ a number of staff, you could be vicariously liable for their acts and omissions. It is in your interests to ensure that any employee or independent contractor working in your practice subscribes to an indemnity or insurance scheme in their own right.
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