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Seeing the wood for the trees

01 February 2006

Mr V, a 20-year-old postman, went to his GP, Dr F, reporting pain in his groin and sore and inflamed foreskin. Dr F found a mild phimosis and treated Mr V with a course of combined anti-fungal and antibacterial cream.

This cleared things up initially, but the problem returned and Dr F eventually sent Mr V to his local urology department. Mr V underwent circumcision, but still had troublesome outbreaks of balanitis, which Dr F treated intermittently with the same cream as before.

Mr V consulted Dr F several times complaining of weight loss and recurrent bouts of diarrhoea. Dr F prescribed a course of ciprofloxacin and referred him to a gastroenterologist. Mr V also attended a well-man clinic at the practice; urinalysis was not carried out.

At the gastroenterology clinic nine months later, Mr V had a normal sigmoidoscopy and unremarkable screening blood tests. Over the next few months, Mr V was seen several times at the gastroenterology clinic and had multiple investigations including colonoscopy, which gave no clue as to the cause of his persistent and worsening weight loss and diarrhoea.

Urinalysis was not carried out at any of his outpatient appointments, nor was his plasma glucose measured. Shortly after, he was admitted to hospital for investigation and discharged a few days later without a diagnosis and still suffering the same symptoms.

A few months later, Mr V’s illness was causing him to miss work and his employer sent him to an occupational health physician, who noted 1% glycosuria and wrote to the gastroenterology clinic to inform them. Two months later, Mr V saw a reflexologist who noted that his weight had dropped by three stones and found a BM reading of 14.1 mmol/l. The reflexologist phoned Mr V’s GP and suggested urgent investigations for possible diabetes mellitus. No action was taken.

Another two months later, Mr V was seen again in occupational health and urinalysis showed 2% glucose, some ketonuria and a random BM of 17 mmol/l. A further letter was sent to the gastroenterology clinic. Again, no action was taken but the specialised gastroenterological investigations continued unabated.

Over two years after the onset of his symptoms, Mr V developed troublesome urinary incontinence; a registrar at the gastroenterology clinic noticed his distended yet painless bladder. Mr V was admitted to hospital and insulin dependent diabetes mellitus was diagnosed. Unfortunately, Mr V had already developed significant complications as a result of his untreated hyperglycaemia, the worst of which was autonomic neuropathy severely impairing his bladder, bowel and sexual function.

When the inevitable legal claim was received, an expert endocrinologist marked it as probably the worst case of failure of diagnosis that he had come across and indefensible. He criticised the failure to test blood glucose levels when Mr V was treated for the phimosis and balanitis, saying: ‘Dr F should have tested the urine when he made the diagnosis of balanitis … but the hospital would appear to be more culpable given the many opportunities for urine testing and measurement of blood glucose’.

Future control of Mr V’s diabetes, in the face of his bowel problems, was anticipated to be difficult and would significantly reduce his life expectancy, by about a third according to the estimate of an expert diabetologist.

Expert opinion

A GP expert stated that ‘many opportunities were lost for diagnosing this patient’s diabetes’, noting the failure of the hospital to respond to the concerns of the occupational health physician, and Dr F’s failure to heed the unequivocal observations of the reflexologist. We settled the case for a sum equivalent to more than £1 million (US$1.75 million). Dr F was held to be 40% liable and the hospital 60%.

Learning points

Urinalysis – This is a vital tool for picking up undiagnosed diabetes.

Unfortunately, as a ‘routine’ test, it is often overlooked or ignored. This is not good practice; those in charge of the organisation of hospital outpatient or primary care screening clinics should heed the lessons from this case and ensure that urinalysis is carried out on all patients, or a reason recorded for why it was not done.

  • Common things occur commonly – The gastroenterology clinic were focusing on Mr V’s illness through highly specialised spectacles; take care that you do not neglect to consider common-or-garden diagnoses from outside your field.
  • Listening to colleagues – There can be no excuse for the hospital’s failure to heed the occupational health physician’s advice, nor Dr F’s failure to respond to the reflexologist’s eminently sensible observations. Alternative healthcare practitioners will play an increasingly important role in disease management; their observations, if formally communicated to a doctor, should not be ignored.
  • Systems – The reasons why the occupational health doctor’s comments were not acted upon were unclear. Were the letters received? Were they seen before filing? Could the same thing happen in your clinic?

Do you have an adequate system in place to ensure that all clinical information about a patient is taken into account when they are seen? There are no easy answers, but it’s worth considering how your systems work and whether they can be optimised to prevent a similar disastrous outcome.