Mr A was an IT consultant in his mid-thirties when he went to see his GP, Dr O, about a pilonidal sinus. During the consultation Dr O checked Mr A’s blood pressure: it was 170/120 mm Hg. Mr A had a family history of ischaemic heart disease and a BMI of 29. He had never smoked.
Blood was taken for a cholesterol level. Dr O suggested that his blood pressure should be measured again in a few days, although there is no mention of this happening. The test came back showing that Mr A’s cholesterol level was a bit high.
Dr O made a note that he should be sent a leaflet about diet, and that his cholesterol should be checked in six months.
Mr A attended his GP surgery several times in the following years for a variety of unrelated, minor problems. At no time were any of these recommendations acted on.
There is no record of any further blood pressure or cholesterol tests. Seven years later Mr A developed slurred speech and went to the A&E department of his local hospital. His blood pressure was 230/134 mm Hg.
He gave a history of morning headaches over the previous year. On examination, he had slurred speech and an expressive dysphasia. A CT brain scan revealed an infarct. The neurological registrar diagnosed a probable lacunar infarct.
Mr A brought a case against all the GPs involved in his care over the previous seven years. He claimed that they failed to diagnose and treat his hypertension, which led to him suffering a stroke.
GP experts were critical of Dr O and his colleagues’ failure to recheck Mr A’s blood pressure, despite it being significantly raised on the first occasion that he attended. In particular, they pointed out that, although Dr O had asked for Mr A’s blood pressure to be rechecked, when he made a comment about sending diet information, he did take the opportunity to remind Mr A to have his blood pressure checked.
Similarly, the expert felt that, when other GPs in the practice saw Mr A for the first time, they should have taken the opportunity to review his records, which were hardly voluminous, and checked Mr A’s blood pressure.
A stroke medicine expert felt that the persistent and untreated hypertension was the most likely cause of the stroke. The case was settled for a sum of almost £675,000 (US$1.3million).
- If you decide that follow-up is needed (eg, a raised blood pressure needs retesting) then it is good practice to make sure that the systems are in place for this to happen. GP record-keeping software now offers some sophisticated features, which may be able to deliver this for you. It is worth reviewing the procedures in place in your practice, to see how they would cope with such a situation.
- A quick review of a patient’s past history is always a good idea, either before or during a consultation. In the UK, the GMC’s Good Medical Practice advises that good clinical care should include “an adequate assessment of the patient’s conditions, based on the history and symptoms and, if necessary, an appropriate examination”. If the history is easily available this should clearly be checked.
The British Hypertension Society has published comprehensive guidelines for management of hypertension, www.bhsoc.org
For current guidance on the management of patients with hypertension see www.nice.org.uk.