Before going on holiday to Kenya, Mr A visited his GP’s surgery where he saw nurse J for advice on travel prophylaxis. She documented his previous immunisations and gave tetanus and polio boosters, noting that he already had some malaria prophylaxis tablets. The dosage regimen and type of tablets were not recorded.
A short while after returning from his trip, Mr A was unwell. He saw his GP, Dr C, and gave symptoms of shivering, diarrhoea and bilateral back pain radiating to the lower abdomen.
Dr C thoroughly examined Mr A and found only pyrexia, without specific clinical signs. Working on a diagnosis of gastroenteritis, Dr C recommended plenty of fluids and temperature-control methods.
Four days later, Dr C spoke to Mr A by phone. Mr A told him that his temperature was still up, he was constantly thirsty, sometimes confused and still vomiting. Dr C visited Mr A at his home and found a persistent pyrexia, tachycardia, tachypnoea and borderline hypotension, with signs consistent with consolidation at the right lung base.
Dr C’s differential diagnosis was pneumonia and/or malaria, prompting him to refer Mr A urgently to his local general medical team. Mr A needed to be admitted to ITU for ventilatory support; the diagnosis was confirmed as malaria with secondary pneumonia.
Dr C’s records were of a high standard. He had noted all relevant findings and important negative ones. He did make one retrospective note, but this was clearly marked as such. It concerned the history of Mr A having taken malarial prophylaxis.
Dr C documented the date of entry and the date of finding out about the prophylactic medication. Once again, however, the exact nature of the prophylaxis taken wasn’t detailed.
Mr A lodged proceedings against Dr C, alleging negligence in that he had diagnosed gastroenteritis on the first visit. Mr A also alleged that Dr C should have visited, diagnosed and treated him earlier in the four-day period. He alleged long-term psychiatric problems as a result of his malaria.
We sought the opinion of a GP expert, who had only one criticism of Mr A’s treatment. This was directed at nurse J and Dr C, and concerned the failure to fully elucidate the nature and suitability of the malaria prophylaxis used.
However, he considered the rest of Dr C’s actions as good, reasonable practice. The claim from Mr A was abandoned at trial, as the deficiencies he alleged were not supported by expert opinion.
- The quality of Dr C’s notekeeping made this action relatively easy to defend.
- A retrospective note is acceptable in clinical records, as long as it is clearly marked as such.
- When taking details of medication, it is important to record exactly what is being taken, the dose and its frequency.
- Malaria prophylaxis is a complex and rapidly changing area of knowledge. It is important to use up-to-date reference sources to decide on the appropriate prophylactic regimen, for travellers to any particular area.
- Assuming that old medication from previous trips will be adequate is a risky strategy.