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Investigate rectal bleeding

01 May 2004

Mr S was 42. He consulted his GP, Dr K, when he noticed he had passed red blood with his stool. Dr K examined Mr S’s abdomen, finding no abnormality, and did a rectal examination. He found a small pile and nil else of note.

Dr K wrote the following entry in the notes, ‘RSOS for further investigations’. No follow-up appointment seems to have been made, but Dr K later stated that his abbreviation meant that Mr G was to ‘return as soon as possible’. This didn’t happen and Mr G failed to keep an appointment with another member of the practice, Dr R, three months later.

Mr S was next seen at the surgery about a year later. On this occasion he saw Dr G, who noted a history of irregular bowel motions and passing of further blood PR. Dr G did a rectal examination, again finding a small pile, and arranged for a faecal occult blood test.

The test result was positive; the report was placed in Mr A’s medical record but then seems to have been overlooked, as no action was taken. Dr G later added the following to the notes: ‘TCA 1/52 or 2/52’.

This was not a contemporaneous entry, Dr G having added it later because he believed that he had asked Mr S to do this, but hadn’t recorded it at the time.

Several more months passed and then Mr S saw Dr F, who sent him to the local hospital for investigation. A colonoscopy revealed a rectal carcinoma. Mr S underwent an abdominoperineal resection and had adjuvant chemotherapy.

Legal proceedings against Drs K and G alleged negligence for their failure to have sufficient regard for the history of PR bleeding, and for failing to perform or refer for further investigation.

Expert opinion

Expert advice was critical of Dr R for not attempting to contact Mr S when he missed his appointment, given that his colleague had recorded a history of PR bleeding and a wish to investigate it further. However,
Dr K’s cryptic abbreviation may not have made this entirely clear.

Drs K and G were criticised for their inadequate investigation of the rectal bleeding, and it was felt that Mr S’s prognosis would have been significantly improved with an earlier diagnosis. It may also have been possible to treat him without such extensive surgery, sparing him a colostomy. The case was indefensible.

Learning points

  • In these days of shared care, it is more important than ever to use commonly accepted abbreviations in patients’ notes, so that they can be easily understood by colleagues. 
  • Keeping track of test results is a major problem for busy practices, and it is essential to have a system in place for checking that they have been seen and actioned by a doctor. The system should be monitored at intervals to make sure that it is operating effectively. 
  • If additions to the notes are made retrospectively, they must be clearly annotated with the date of entry. Failure to do so will hamper,not help, in any legal action. 
  • With a symptom as serious as rectal bleeding, where neoplasia is a potential diagnosis, prompt and appropriate investigation is mandatory. Current guidelines – for example, Department of Health referral guidelines in the UK – recommend immediate referral for endoscopic or radiological imaging of the large bowel for patients with a history of passing blood PR and altered bowel habit.