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Repeat offender

01 January 2011

Mrs B was a 49-year-old deputy headteacher who, for 18 months, had been increasingly troubled by heavy irregular menstrual bleeding. She was referred to a gynaecologist who carried out a pelvic US and an endomentrial biopsy. In her follow-up appointment with the gynaecologist, Mrs B was told that her investigations had been normal and hormone replacement therapy (HRT) was suggested to regulate her bleeding. The gynaecologist told Mrs B that he would be writing to her GP with his opinion and treatment recommendations.

Mrs B was therefore advised to go and see her GP to get a prescription for HRT in two weeks, which was thought to be sufficient time for the clinic letter to reach the GP. In the meantime, the gynaecologist scribbled down the name of the recommended HRT and gave it to Mrs B.

Two weeks later, Mrs B duly took the afternoon off work and went to see Dr M, a locum, at her GP surgery. Unfortunately no clinic letter was available to Dr M on the practice computer notes. Unfamiliar with the practice’s administration systems, Dr M attempted to find out if a paper copy of the letter might be available somewhere.

Dr M asked reception staff and personally looked through the partners’ piles of post but the letter could not be found. By now Dr M was running late and was sensitive to Mrs B’s frustration at having taken time off work for “a waste of time”. Eager to help Mrs B, Dr M looked at the handwritten note the gynaecologist had given her. The writing was barely legible, but Dr M thought the medication looked most like unopposed oestrogen.

Mrs B’s blood pressure was satisfactory and it was recorded that Dr M counselled her about risks of breast cancer and thromboembolic disease. Mrs B left with a prescription for unopposed oestrogen.

Mrs B continued to be prescribed three-monthly prescriptions of the unopposed oestrogen. The GP who signed the repeat, Dr P, saw from Dr M’s consultation notes that Mrs B had been seen recently by a gynaecologist and the prescription had started as a result of this, and was therefore satisfied it was appropriate.

At six months she was seen in surgery by Dr T for a review of her HRT. Dr T again noted her attendance at the gynaecology clinic and recorded that a course of unopposed oestrogen was started by the gynaecologist. Mrs B’s blood pressure was taken and it was recorded that she was regularly self-examining her breasts.

The prescriptions continued for a year, when Mrs B was again called for a HRT review at the surgery. At this point she surprised Dr T by saying that the HRT wasn’t helping her bleeding that had recurred and which was, in fact, heavier and more persistent than ever. 

Dr T realised that for many months Mrs B had been mistakenly prescribed an unopposed oestrogen and now had heavy bleeding. Dr T apologised to Mrs B and also explained that she needed to be quickly referred back to the gynaecologist for investigation. She was referred urgently and in view of her history of increasingly heavy bleeding and prolonged exposure to an unopposed oestrogen, a hysteroscopy was carried out. This led to a diagnosis of endometrial cancer. Mrs B had a hysterectomy and made a full recovery.

She made a claim against all the doctors involved in her care at the GP practice. The gynaecologist’s original letter was eventually found in the patient’s notes.

Expert opinion

The incorrect prescription could not be defended – Dr M was responsible for her actions.

An expert gynaecologist advised that the patient’s subsequent problems were probably a result of this (although there was a low probability that they may have occurred in any case). The practice was liable because there was no system in place to check the prescriptions and uncover Dr M’s mistake.

The confusion could have been avoided if the consultant had issued the first prescription. In shared care situations there is a reduction in risk if the initial prescription is commenced by secondary care.

The claim was settled for a moderate sum.

Learning points

  • GPs must take particular care when taking responsibility for prescribing treatment commenced in the hospital sector. If you sign the prescription, you are responsible for it, so make sure that it is correct. If a drug is unfamiliar, don’t prescribe it if you don’t have the knowledge/experience.
  • Practices should have a system for ensuring all incoming mail is checked and acted upon. There was a lost opportunity to correct the error when the hospital letter was received.
  • Repeat prescribing is particularly risky for locum GPs. Locums should consider whether there is anyone better placed to do it, such as another GP who is more familiar with the patients. See MPS’s factsheet on “Safe Prescribing” and an article in Sessional GP.
  • Any GP doing repeat prescribing must ensure that the prescription is still necessary/correct.
  • This case highlights the importance of being open and honest if you make or discover a mistake.