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01 January 2009

Mrs E was an overweight school cook in her 50s who had type 2 diabetes and smoked 20 cigarettes a day. She developed a cough on the flight home from a holiday in Cyprus and, one week later, went to see her GP, Dr R. The cough had become productive of green sputum and she said she was also feeling extremely tired and generally unwell.

He noted that she was afebrile, but had some crepitations in the right lung with scattered rhonchi bilaterally. Dr R diagnosed a lower respiratory tract infection and prescribed a course of amoxicillin, asking her to return once the course was finished if she felt no improvement.

Two weeks later, at the end of a busy evening surgery, Dr R took a telephone call from Mrs E to say she still felt unwell, was still coughing up yellow phlegm and wondered whether she needed another course of antibiotics. There were no appointments available that day and she said she didn’t want to come in and bother him, but would like it if she could just get a prescription for another antibiotic. Dr R said that seemed like a good idea and he would leave another script for her at reception. He prescribed some co-amoxiclav for her on the computer, but did not make an entry in Mrs E’s record of the details of the telephone consultation, or whether anything else was discussed at this time.

Another two weeks passed and Mrs E called her local out-of-hours service late one evening. She told them she had been treated with two courses of antibiotics during the last month, which had made little difference to her, and that she was still coughing and chesty and now breathless. She said she would like to see a doctor and requested a house visit as she felt she was too unwell to attend the out-of-hours clinic.

She was visited by Dr G, who examined her and noted good air entry and that auscultation of the chest was normal. He did not elicit a history of diabetes. Mrs E told him that, in addition to the cough, she had been vomiting intermittently throughout that week, so he prescribed her a short course of cyclizine. There were no records of any blood glucose level in the out-of-hours notes, or any instructions for review if the symptoms were not settling.

The following morning, Mrs E’s husband found her wandering in the garden, confused and feverish. He phoned for an ambulance and she was admitted to hospital with pneumonia and unstable diabetes, but unfortunately later that day suffered a myocardial infarction and died. Mrs E’s husband began a claim against Drs G and R.

Expert opinion

Expert opinion was critical of the care provided by Dr R during the telephone consultation, and the home visit by Dr G. It was felt that admission to hospital on either occasion would have enhanced Mrs E’s chances of survival. The case was settled for a low sum.

Learning points

  • Telephone consultations require skill. Special considerations include difficulties with non-verbal cues; obviously on the telephone it is much harder, if not impossible, to pick up on these and there can easily be misunderstandings by either doctor or patient. There is also a temptation to interrupt patients too early in the history, or to hurry them along, particularly if several more patients are waiting in line for telephone consultations. It is important to remember to safety net and to record the substance of the consultation accurately in the patient’s notes. Care should be taken in prescribing antibiotics after a telephone consultation.
  • Doctors working for an out-of-hours service and carrying out a home visit are unlikely to know the patient or their entire medical history. It is therefore important to ask about previous medical history that may have a bearing on the current complaint. If Dr G had known that Mrs E was diabetic, the significance of her vomiting might not have escaped him.
  • There should be an efficient communication system between out-of-hours services and the patient’s own GP, so that a review can be recommended if necessary.
  • Readers might wonder why the damages awarded in this case were low, given that the patient died. Damages, however, are not an indicator of the severity of the effect of negligence. See Miller, K, What’s it Worth?, UK Casebook 14 (May 2006) for an explanation of how damages are assessed.