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A missed opportunity

01 September 2007

Mrs A, a 34-year-old school secretary, registered with a new GP practice when she moved house. As part of her routine registration health check, she had her urine analysed by the practice nurse and proteinuria +++ was detected.

Dr D saw Mrs A immediately after this and issued a repeat prescription for her long-term antidepressant medication. No comment upon the proteinuria or a plan of investigation was recorded in the notes. Dr D saw Mrs A one month later when she was having difficulty coping in her job due to depression and a family crisis. Again, no comment was passed upon the proteinuria.

Seven months after this, Mrs A came to see Dr E as she had suffered a few days of urinary frequency and urgency with dysuria. Dr E prescribed a course of trimethoprim, but did not ask for a urine sample. Dr E’s record made no reference to the proteinuria detected at registration, so presumably he had not noticed.
Mrs A saw Drs D and E for a range of unrelated minor complaints over the next three years. After an acute illness she was admitted to hospital and found to be suffering from acute on-chronic renal failure of uncertain aetiology. Her condition progressed over the next few years to end-stage renal failure requiring dialysis, and ultimately she had a successful renal transplant.

Mrs A started a legal claim against both doctors, alleging negligence in failing to take notice of, or act upon, her significant proteinuria when she first registered with the practice.

Expert opinion

A GP expert thought the practice’s system for reporting new patients’ abnormal urinalysis results was extremely flawed. Often the nurse wrote up her notes whilst the patient saw the doctor, and this information was placed in the file later.

Dr E was criticised for not looking back to check the recent urinalysis that he knew would have been conducted at the registration visit, when he saw Mrs A shortly after with a urinary complaint. Even if he had not done this, it was felt that repeat urinalysis and urinary culture should have been performed, given Mrs A’s symptoms. The case was settled for a moderate sum.

Learning points

  • Urinalysis is an extremely useful and inexpensive screening tool in both primary care and hospital outpatient/emergency settings for detecting occult diabetes or urinary-tract pathology. Unfortunately, its widespread use often leads to it being overlooked, being seen as something “that is just done”. It should be considered as an investigation result like any other, and failure to act upon an abnormality can lead to missed opportunities to treat or prevent serious disease.
  • It is important to have systems in place that allow all the relevant information from a patient’s previous consultations, diagnoses, medication and recent investigations to be taken into account during a consultation. This is particularly important when patients first register at a practice, as information lost at this stage may cause and compound error in future visits.
  • Dr E was criticised for not checking back to a previous consultation. It is good practice to review quickly what happened the last couple of times the patient was seen, particularly when seeing a new patient.

Further information

A study of 400 clinical risk self-assessments carried out by MPS Risk Consulting in the UK in 2006 found that 84% of practices had risks associated with test results. These risks included:

  • Not having a tracker system in place to ensure that patients are followed up.
  • Not having a system in place to show when all of a patient’s test results have been returned.
  • Not recording test results onto a computer.
  • Allowing non-clinical staff to inform patients of their results and the treatment required.