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The clue is in the water

01 September 2011

Miss W was a 20-year-old shop assistant who lived at home with her parents. She had to go home from work because she felt dizzy and nauseous. She went home and was sick, and developed earache, so she made an appointment with her GP.

Her GP diagnosed an ear infection and prescribed her some antibiotics. A week later she was much worse. She was vomiting several times a day and the dizziness was becoming intolerable.

She also had a ringing in her ears that would not cease. Her mother was concerned and rang her GP, Dr T, who agreed to visit the same day. Dr T noted the dizziness and tinnitus, and documented that her pulse and blood pressure were normal. He also noted that there was no nystagmus or signs of dehydration.

He diagnosed vestibuloneuritis and prescribed some stemetil to help with the dizziness. Dr T made clear and comprehensive notes following the visit and asked Miss W to ring if the situation did not improve with the treatment. Miss W’s mother rang the GP surgery the following day requesting a visit because her daughter had made no improvement at all.

She was feeling very weak and it was the fifth day that she had been bed bound. Dr T spoke with her mother over the telephone rather than arranging a home visit. Dr T was concerned that the continued vomiting could be causing dehydration so asked about her urine output. Her mother answered that she was passing "a huge amount of urine and she was drinking a lot”. Dr T recorded: “Good urine output, drinking well, not dehydrated. Continue treatment.”

Miss W deteriorated over the next two days. She became confused at times and felt an incredible thirst that seemed unquenchable. Her mother continued giving her the stemetil, hoping that she would improve with time as the GP had said. Miss W slept most of the day and when her mother tried to remind her to take her medication, she was unable to wake her.

She phoned the emergency services in panic. Once in hospital the doctors noticed a smell of ketones on her breath and her severely dehydrated state. She was diagnosed with diabetic ketoacidosis. Despite all appropriate treatment she was left with some serious neurological impairment.

Miss W and her mother made a claim against Dr T. The experts considered that although the initial assessment was reasonable, the telephone consultation should have alerted Dr T to the possibility of diabetes, given the history of polyuria and polydipsia. The case was settled for a high amount, reflecting the level of harm to the patient.

Learning points

  • Diagnosis is a dynamic process that needs revisiting with an open mind. Had Dr T noted the information about Miss W drinking excessively and passing a lot of urine prior to the “label” of vestibulo-neuritis, he might have considered diabetes. His own diagnosis prevented him from seeing the full picture.
  • It is important to remember that patients with diabetic ketoacidosis can deteriorate very quickly.
  • Any patient with deteriorating symptoms needs reviewing. Young healthy people with minor complaints tend to recover fairly quickly. If this does not occur, alarm bells should ring.
  • Telephone consultations have inherent risks; if you decline a home visit you should be satisfied that you’ve taken a thorough history. The diagnosis might have been aided by an examination revealing the smell of ketones and signs of severe dehydration.
  • It is important to try to speak directly with the patient and if they are not well enough to talk to you, this should raise concerns.