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Lost opportunity

26 July 2017

Ms C, a 43 year old smoker who was otherwise well, presented to her GP, Dr Q, complaining of a few days discoloration to the tip of her right index finger.  She explained that her fingers have always felt cold and often turn white and go numb when she is outside.

When Dr Q examined the finger, there was purplish discoloration of the tip and it felt cold.  He noted the presence of good peripheral pulses. Dr Q advised her to stop smoking and made a non-urgent referral to the vascular team.

Nine days later, the patient consulted a second GP, Dr P, as the fingertip had become painful.  The records of this consultation were limited, but he diagnosed cellulitis and prescribed fluxcloxacillin, with an appointment for review in 10 days.

When Ms C returned for review, her finger was much better but she now complained of tiredness with some back pain, which she thought was related to her periods.  Dr P arranged some investigations, including full blood count, urea and electrolytes (U&Es), liver and thyroid function tests and planned a further review with the results.

The next day, the results were available and alarmingly revealed some abnormalities.  Her eGFR was just 22, urea 14 (2.8 – 7.2); creatinine 211 (58-96); albumin 33 (35-52). The results were reviewed by a third doctor, Dr B, who arranged to see Ms C the next day.  As there were no previous U&Es, Dr B arranged for repeat set of bloods, including an ESR.  He also arranged an urgent renal ultrasound scan.

The repeat bloods showed creatinine 216, urea 10.7 and ESR 104.  These were reviewed by Dr P, who took no action as the renal ultrasound scan was to be carried out three days after that and the patient was due to be seen by Dr B for review thereafter.

At that review, 8 days later, Dr B noted the U&Es were still abnormal and decided to await the results of the ultrasound scan.  The ultrasound result was delivered the next day, which stated that “both kidneys demonstrate slight increase in cortical brightness; otherwise both kidneys are normal size, shape and morphology with no pelvi-calyceal dilatation”. The results were filed by Dr P as no major abnormality was demonstrated.

One and a half months later, Ms C was admitted to hospital with a subarachnoid haemorrhage. On admission, her GCS was 11, BP 175/103, and the creatinine 573, urea 50 and albumin 29.  The patient was referred to a neurosurgeon who organised a CT scan, which confirmed blood in the interventricular systems. An angiogram was performed, which revealed a left pericallosal aneurysm, which was successfully embolised. There were also noted to be other aneurysms. Ms C was initially aphasic with significant neurological impairment after the first procedure.

Ms C was also seen by a nephrologist in light of her significant renal impairment.  She was found to have +++proteinuria and +++blood in her urine. Further investigation revealed raised inflammatory markers, mild anaemia and the presence of antinuclear antibody. A repeat renal ultrasound showed two normal kidneys. A renal biopsy was performed, which revealed acute necrotising glomerulonephritis.

A potential diagnosis of systemic vasculitis was made. She was commenced on peritoneal dialysis, high dose oral prednisolone and cyclophosphamide. Ms C eventually required renal transplantation, three months after the presentation with subarachnoid haemorrhage.  Her kidney function stabilised thereafter.  

In conjunction to renal support, Ms C was successfully treated for the multiple aneurysms, recovered from her aphasia.  Her neurological deficit improved, such that she was able to mobilise, all be it with assistance. 

Following discharge from hospital, Ms C brought a claim against Dr P and Dr B, alleging they failed to refer her to a renal specialist when the abnormal U&E results were initially found. 

Medical Protection instructed experts in General Practice, Nephrology, Neurology and Radiology to assist in managing the claim. 

Expert opinion

The GP expert opined that a reasonably competent GP should have checked the patient’s urine on the first consultation after the increased creatinine was noted, as proteinuria and blood in the urine would more than likely have been present. Urgent referral to a renal specialist would have been appropriate at that stage.  He was critical of Dr B for waiting for a second blood sample and ultrasound. Furthermore, when the second set of blood results were reviewed and then the ultrasound report received, Dr P should have referred the patient.

The nephrologist expert considered that end stage renal failure would have been deferred but not avoided if the patient had been appropriately diagnosed and treated earlier. As there was no evidence of polycystic renal disease, he did not consider there was any connection between the kidney disease and the cerebral aneurysms. However, it is noted that although the pre-subarachnoid haemorrhage blood pressure was not available, the blood pressures at the time of the haemorrhage were elevated.  It was felt that if Ms C had been referred earlier, any hypertension would have been treated aggressively. The neurologist expert considered that strict control of blood pressure would have been sufficient to prevent the subarachnoid haemorrhage.

On the basis of the critical expert reports the case was settled for a substantial sum. 

Learning points
  • Seeking specialist advice or referral early may be appropriate in certain situations. Good communication is essential for continuity of care between primary and secondary care
  • Guidance on the management of AKI is available from the National Institute for Health and Care Excellence in the UK:
  • Correlation of investigation results with the clinical picture is essential and could have avoided the renal ultrasound being filed in this case without further action being taken
  • Carrying out simple tests in primary care such as urine analysis and blood pressure should always be considered and may affect a patient’s management and the eventual outcome. 
  • Ultrasound scans can be falsely reassuring and needs to be correlated with the clinical features. In this case the cause of the renal failure was not clear and warranted further investigation, rather than the ultrasound scan alone offering reassurance.