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A routine referral?

02 September 2019

Mrs F, a 48-year-old office worker, attended her GP, Dr A, complaining of unilateral headache in conjunction with double vision and nausea. Dr A considered the symptoms may be due to migraine but, as examination elicited nystagmus on looking to the right, an urgent referral to neurology was made. The remainder of the neurological examination, including fundoscopy, was normal.

Mrs F was offered a neurology appointment for a date approximately three weeks later, but failed to attend. She was therefore discharged and sent a letter to say that if she wished to have a further appointment, she needed to be re-referred by her GP.

Two weeks after the missed appointment she attended the GP practice again, this time seeing Dr T. She complained of several non-neurological symptoms, and at the end of the consultation mentioned in passing that she had missed the neurology appointment and needed another referral.

Dr T requested that the practice administrative staff forward the original referral, which they duly did; however, this time the referral was inadvertently marked routine rather than urgent. An appointment was therefore offered for a date approximately five months later.

During the wait to see the neurologist, Mrs F attended the GP practice on a number of other occasions to complain of headaches with flashing lights and occasional double vision. Migraine continued to be the working diagnosis. Dr T performed another neurological examination, which was documented to be normal. Dr T also performed fundoscopy as part of the examination, but as this was normal she did not specifically document it.

Mrs F was reviewed in the neurology clinic a month after this appointment, and again a normal cranial nerve examination was documented, along with specific documentation that fundoscopy was normal. A diagnosis of migraine was made, and amitriptyline was offered.

Six weeks later, Mrs F attended for a routine optician appointment, where papilloedema was identified – and she was referred to the emergency department for further review. Magnetic resonance imaging identified a right-sided acoustic neuroma and Mrs F went on to have this surgically removed.

A claim was brought against Dr T, alleging that the repeat referral letter should have been marked urgent, and that the neurological examination at the second consultation with Dr T should have included fundoscopy, or documentation of the same if it had been performed.

It was alleged that had papilloedema been identified at an earlier time, imaging would have been performed sooner and the acoustic neuroma would have been removed when it was smaller, reducing the severity of Mrs F’s postoperative disability, which included a facial palsy, balance impairment and right-sided deafness.

Expert opinion

Medical Protection instructed a GP expert to review the claim.

The GP expert considered that Dr T had performed an appropriate assessment of Mrs F’s symptoms, and was not critical of a failure to specifically record that fundoscopy was normal when it was performed as part of a neurological examination.

However, the expert was somewhat critical that the copy of the referral letter was marked routine rather than urgent. Although he also commented that as the subsequent neurological examinations of Mrs F were normal, there would have been no requirement to expedite the referral once it had been sent. 

In addition, subsequent fundoscopy performed on Mrs F, including by the neurologist, was normal – meaning that it was unlikely to have been present at an earlier time, and therefore would not have been identified earlier than it was.


On the basis of the GP expert report, medical records and the evidence of Dr T, Medical Protection argued that the actions of Dr T were appropriate and that papilloedema would not have been identified at an earlier time, thus the outcome for Mrs F would have been no different.

The claim subsequently discontinued.

Learning points

  • Consider documenting in the records that a specific examination, such as fundoscopy, has been performed, even if the findings are normal. This will help to avoid any future allegations that the examination has not been conducted.
  • Take care when delegating tasks to non-clinical staff and give clear instructions about the urgency of any referrals, where appropriate. GP partners can be held liable for the actions of their administrative staff.
  • Beware “Oh, and by the way…” comments at the end of a consultation – on a busy day, it may be easy to miss a matter of importance to the patient.