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Change your diagnosis, not the records

01 November 2003

Miss Y was a healthy, happy schoolgirl until the age of 15 when she started getting headaches. She saw a locum at her GP practice, giving a six-month history of persistent headaches with vomiting and a stiff, twisted neck. She mentioned a family history of migraines. The doctor diagnosed migraine and prescribed analgesia and pizotifen.

There was no record of a neurological examination.

Two months later, Miss Y went to an optician, who sent a general ophthalmic services form to Dr S, Miss Y’s GP. It stated, ‘Fundoscopy showed no optic cup R + L. There is evidence of myelination of the optic disc (R + L).Pupils’ reaction was sluggish. No abnormality detected.’

The heading stating, ‘I am referring this patient to you because …’, was crossed out, and replaced by, ‘For your info. only’. This simple change in emphasis had a bearing on subsequent events.

Four weeks later, Miss Y saw Dr S, describing occipital headache and nausea. A neurological examination is recorded as being normal, although pupillary reactions and fundoscopy aren’t documented. Dr S referred Miss Y to a paediatrician.

Five days later Miss Y was back at the surgery and saw Dr V. Dr V noted a left seventh-cranial-nerve palsy affecting Miss Y’s lower face. This information wasn’t passed on to the paediatrician due to see Miss Y, nor was an attempt made to speed up the appointment.

The next day Miss Y went to A&E. A diagnosis of migraine leading to cranial nerve palsy was made. Miss Y was sent home with a note advising her GP that an appointment had been made at the neurology outpatient clinic.

A week later, Miss Y was seen on a home visit requested by her mum, who was worried that Miss Y was excessively sleepy. When Dr V arrived, Miss Y was alert and he took no further action.

These were the last dealings Miss Y had with her GP practice. Her symptoms were bad enough to send her back to A&E, where she was given more pizotifen. Her vision worsened so she saw another optician, who immediately diagnosed bilateral papilloedema, and sent Miss Y urgently to a local eye hospital. From there she was sent to a specialist neurological unit.

Miss Y had a pineal blastoma and secondary hydrocephalus. She required treatment to drain the hydrocephalus, a craniotomy to debulk the tumour, and craniospinal irradiation. Miss Y was left with poor, monocular vision, marked emotional lability and significant behavioural difficulties. She was cared for in a high-dependency unit for neurologically impaired young adults.

A legal claim naming her GPs, the A&E department and the first optician was started. 

Expert opinion

Expert advice was critical of the care given by Drs S, V and the A&E doctors. By disregarding or failing to appreciate the significance of a progressive combination of symptoms and signs of raised intracranial pressure, it was felt their care fell below a reasonable standard.

The defence of the claim was hampered by the fact that the GP records had been altered. The details of one consultation were written on a record card that had been printed two months after the consultation took place. The signature on one referral letter seemed very different from the doctor’s normal one.

Most of the liability was assigned to the hospital and Miss Y’s GPs, with the locum and optician sharing a smaller portion. One expert noted, ‘She had unremitting headache and vomiting for 10 months … developed a wry neck and then a facial palsy as further evidence of organic dysfunction ... she suffered a deterioration of her vision in her left eye … accompanied by abnormalities of her pupillary reactions … noted by several observers.’

The optician had a statutory duty to recognise disease or injury of the eye and refer it to a medical practitioner for investigation. She noted the findings and reported them to a doctor, which largely discharged her duty of care.

However, she altered the emphasis of the ophthalmic form (to ‘for information only’) and came to the wrong conclusion about the reasons for Miss Y’s sluggish pupillary reactions and optic disc abnormalities. This fell below the standard that would be considered acceptable for optometrists.

The claim was settled for a large sum.

Learning points

Clinical information is best considered in its entirety. Miss Y’s doctors failed to link her symptoms, neurological and ocular findings. If someone had reviewed the diagnosis, which wasn’t typical of migraine and was unresponsive to therapy, Miss Y would have fared much better. Once she was labelled as having migraine, other alternatives were discounted.

Miss Y’s notes had been changed, a fact that was revealed by an audit trail. The reasons for these changes may have been entirely innocent, but these reasons were not documented.

Medical records should not be altered or amended. If you discover a mistake, insert an additional note as a correction. Make it clear that this is a new note, not an attempt to tamper with the original record. More advice can be found in the MPS booklet on keeping medical records.

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