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Haematuria not investigated

01 November 2003

Mr B, a 60-year-old snooker club manager, went to see his GP, Dr D, after passing blood in his water. Dr D found nothing else of note in the history and examined the abdomen, genitalia and prostate – all unremarkable.

Blood was visible in the sample Mr B gave for an MSU. Mr B was about to move to a new area. Dr D noted this and recorded that he told Mr B to register with a new GP and be investigated.

The MSU result showed only RBC+, and was filed in Mr B’s notes (stamped by another practice member as normal).Two months later the notes were transferred to Mr B’s new practice. A further two months passed and Mr B went to see his new GP, Dr J, after a minor car crash. The episode of haematuria hadn’t recurred and wasn’t mentioned.

Dr J kept her notes on a new record card. She didn’t see the previous entry about haematuria and there was no review of the notes. It was another four years before Mr B came back to the surgery.He gave a history of recurrent longstanding gross haematuria.

Urinalysis showed RBC++++, Prot+,WBC+.Dr J sent an MSU, checked FBC and U&E, prescribed trimethoprim and referred Mr B to a urologist. Mr B was found to have an invasive bladder carcinoma.

He had a total cystectomy but died from metastatic disease less than a year later.

Legal proceedings against Dr D alleged failure to investigate the haematuria. Dr J was sued for failing to review Mr B’s records and investigate the haematuria appropriately at first presentation.

Expert opinion

GP experts were not critical of Dr D, stating that it was reasonable to ask Mr B to tell his new GP about the problem. One expert criticised the practice for not phoning the MSU result to Mr B and telling him of the importance of investigation.

GP experts disagreed as to whether or not Dr J was obliged to review the notes at Mr B’s first attendance, but there was clearly a danger that a court would find against a doctor for not doing so.

Oncological opinion was that, had referral been made at either opportunity, then a cure was probable.

Eventually the case against the two doctors was dropped – probably because expert opinion was divided.

Learning points

Continuity of care has two sides to it. If something urgent requires action you have a responsibility to ensure that action is taken, regardless of whether the patient is leaving your practice.

When taking on new patients, the ideal would be to check the notes of each of them, but with the rate of turnover of patients these days, particularly in bigger cities, this suggestion is not practical.Many practices use note summarisers to precis a new patient’s notes. If so, it may be worth ensuring in the summariser’s protocol that outstanding investigations should be included in their summary.