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Crying wolf

01 September 2008

Mrs K was a 46-year-old part-time accountant and regularly attended Dr W’s surgery, usually for minor non-specific symptoms. Except for requiring long-term citalopram for anxiety and depression, Mrs K was in good health. She admitted to drinking too much alcohol in the past, but denied having more than a glass of wine on weekends in recent years.

On this occasion she attended surgery, complaining of an episode of severe dizziness and vomiting, which had lasted for two days. She did not experience diarrhoea or palpitations but said she had suffered a headache. Her vomit was neither bloody nor bilious and there was no associated abdominal pain. There was no history suggestive of visual disturbance, muscular weakness or sensory disturbance and Mrs K said she had not suffered any head trauma. The dizziness was not worse on standing, but she described it as spinning in nature. Her symptoms had cleared by the time she saw Dr W and as such he did not perform a physical examination. In particular, Dr W did not examine her vital signs, ears, cardiovascular, gastrointestinal or neurological systems – reassuring her that this was likely to have been an inner ear problem caused by a viral infection. Dr W did not advise Mrs K about what to do if her symptoms recurred.

She attended the surgery again three days later following a similar episode, this time to see Dr  T. Mrs K once again said that the dizziness and vomiting were associated with a headache. The headache was more severe this time. Dr T excluded a diagnosis of meningitis on clinical grounds and was satisfied she was not pregnant. She performed a basic examination, which was normal, but did not examine Mrs K’s neurological system in any great detail. She was advised to visit her optician in case she required new glasses and it was explained that her headaches may be related to eye strain.

Still suffering from these symptoms, Mrs K was seen by another GP, Dr E, a few days later. He carried out a full examination, including her central and peripheral nervous systems, cardiovascular, gastrointestinal and ENT. Dr E did not record any abnormal findings except for a raised blood pressure. He also documented important negative findings such as normal fundoscopy, no nystagmus, no evidence of motor or sensory loss, no aortic stenosis and a soft nontender abdomen. She was started on anti-hypertensive medication and stemetil for her vertigo. Mrs K attended several more times over the next couple of weeks. However, the consultations became more difficult as Mrs K’s husband, who came with her, became quite aggressive and abusive to staff. Mr K insisted the doctors were not doing enough to help his wife and he accused them of being negligent on several occasions.

One evening, almost three weeks after her initial presentation, Mrs K collapsed with loss of consciousness. She was taken by emergency ambulance to the local A&E department where she was stabilised. Clinical examination demonstrated oculomotor and bulbar abnormalities and abnormal motor signs in all four limbs. An MRI scan confirmed a diagnosis of basilar artery infarction (brain stem infarction). While Mrs K regained consciousness she remained almost totally quadriplegic.

Expert opinion

Expert GP opinion was critical of Dr W for failing to examine Mrs K when she first presented with symptoms of dizziness. His allegedly dismissive tone contributed to the bad feeling that persisted throughout the process. The expert was supportive of the care provided by other GPs.

Expert neurological opinion could find no evidence that earlier referral would have prevented the stroke. It was unlikely that anticoagulant therapy would have been given, because of the strong contraindication of hypertension. The claim was eventually discontinued by Mrs K and her family.

Learning points

  • All patients, including regular attenders, may have serious illnesses and should be treated professionally. You should not let prejudices from previous consultations cloud your judgement. 
  • Do not let the emotional heat of the situation prevent a professional assessment. If you feel that a deteriorating relationship with the patient threatens to get in the way of good care, consider getting a fresh view from one of your colleagues.
  • To succeed in a negligence claim, a patient must prove that the care was negligent and that in this case Dr W’s apparent negligence caused the injury. It was not possible to prove that the negligence caused Mrs K’s problems.