Membership information 0800 225 677
Medicolegal advice 0800 014 780

The cost of poor records and a missed diagnosis

30 November 2022

Dr Comfort King, Case Manager at Medical Protection, reviews a recent case where a missed diagnosis was compounded by poor note-keeping.

Dr P was a medical officer who was covering locum shifts within a busy emergency medicine department. He was asked to see a 17-year-old patient, BB, who had presented with a one-hour history of acute left-sided abdominal pain. The pain was described as sudden and excruciating. Her mother was also concerned that she had been vomiting and was extremely restless. She had a history of ovarian cysts and a previous presentation to hospital with pain in the same location, but of a lower severity.

Dr P reviewed the patient and undertook further investigations, including a urine dip, which was negative for pregnancy. He also initiated symptomatic management to address the patient’s pain and vomiting – antiemetics and analgesia.

With a diagnosis of another ovarian cyst in mind, he called the specialist gynaecologist on call to discuss the patient further and consider whether she was suitable for discharge home.

After speaking to Dr U, Dr P discharged the patient with analgesia and gave safety netting advice to the patient’s mother to bring BB back, if the pain persisted for longer than 48 hours.

Patient BB re-presented to another gynaecologist, Dr S, 12 hours later with ongoing pain. An ultrasound of the abdomen was performed and further investigations were undertaken. BB was diagnosed with missed ovarian torsion with gangrenous changes.

An HPCSA investigation and claim then ensued against both Dr P and Dr U.


This matter became very problematic as Dr U reported that he was not aware of the severity of pain or the presence of vomiting. He asserted that if the severity of the symptoms experienced was communicated to him, he would have had a higher degree of suspicion of the diagnosis of ovarian torsion. He reported that the medical officer stressed the fact that he had ruled out a serious gynaecological emergency. He also reported that the conversation that he had with the junior was more of a ‘checking in’ conversation, quite informal in nature, and he did not perceive this as a referral. If he had known that this was a referral, he would have asked further detailed questions.

Dr P said that he informed Dr U of all the findings on examination and the full patient history, and had referred for official guidance from a specialist. If he was confident of a diagnosis of ovarian cyst pain, then he would not have phoned in the first instance. He did admit that he had said that he did not feel there was a serious gynaecological emergency, but only because ovarian torsion was not a differential diagnosis that he considered, and he was in fact referring to the likelihood of an ectopic pregnancy when he made that statement.

This presented difficulties for both clinicians involved for two distinct reasons.

Record keeping

Firstly, let us consider the issue of documentation. Instances such as this illustrate the importance of documentation in clinical practice. Although Dr P had recorded that he had consulted Dr U for advice, he did not actually include the specifics of the discussion, leaving the door open for ambiguity about what was actually communicated. He had not documented that he had communicated with Dr U about the history of vomiting, nor had he recorded that he had raised the question of whether an ultrasound would be appropriate. Instead, his notes read:

“Discussed with on call gynaecologist. Agrees with discharge.”

Dr U, on the other hand, did not have any documentation of the conversation, as he did not perceive it would be required, given the informality of the conversation he thought he was having.

Secondly, there was the issue of the missed diagnosis.

Missed diagnosis: a problem for Dr P?

While a medical professional is not infallible, in formulating a diagnosis the HPCSA makes it clear (in Guideline 5.1.8) that a medical practitioner has a duty to apply their minds when making diagnoses and considering appropriate treatment.

Never forget that although ‘common things are common’, certain diagnoses are extremely important to actively exclude. Ovarian torsion in an adolescent patient presenting with acute iliac fossa pain is one of these; similarly, an ectopic pregnancy in a sexually active woman of childbearing age presenting with lower abdominal pain is another. Missing a diagnosis such as this through failing to perform the appropriate bedside investigations, such as an ultrasound or pregnancy test, is a more difficult position to defend.

Does HPCSA guidance assist with resolving liability for Dr U?

One of the core ethical values of a medical practitioner according to the General Ethical Guidelines for the Health Care Profession contained in Booklet 1, is that medical practitioners should always act in the best interest of patients and, conversely, should not act contrary to those interests. Guideline 6 of the General Ethical Guidelines sets out the duties that practitioners owe to their colleagues. Guideline 6.1.2 envisages that practitioners should treat patients referred to them in the same manner in which they would treat their own and in terms of guideline 6.2.1, they should work with and respect other healthcare professionals in pursuit of the best healthcare possible for all patients. Guideline 7 states that practitioners owe a duty to the patients of other practitioners to act quickly to protect patients from risk due to any reason.

From this one can safely conclude that the guidelines intend you to treat your colleague’s patients, about whom they approach you for advice, as if they were your own. Therefore, as a clinician you should ensure that you put yourself in a position to exercise sound clinical judgment. This involves considering whether you have the patient’s necessary medical history in order to form an opinion on diagnosis, treatment or further management of the patient and if not, it should be obtained from the referring practitioner before pronouncing a diagnosis or providing advice on management. Consideration should be given to whether it may be in the patient’s best interests to be examined personally by you as the advising practitioner in order to form a thorough opinion, and whether a desktop assessment of the patient’s medical case could ultimately result in subpar clinical advice. 

Liability can still be attracted even if you did not see the patient; consequently, it is prudent to ask yourself:

•  Do I have all the information necessary to provide advice on the diagnosis and management of a patient over the phone?

•  Is there any further information I require to make a safe diagnosis remotely?

•  If I was able to review the patient myself physically, would I approach the patient’s management any differently?

Although a referral may appear informal, it is always good practice to ensure that you are informed about the extent to which the advice will be relied on in the patient’s management and consider whether the advice given will be recorded or implemented accurately by the referring practitioner.

Be aware that where it is found that you as an advising practitioner have acted negligently in providing advice, for example not applying your mind to the patient’s medical history or where it would have been more appropriate to have assessed the patient in-person and this was not done, then you as the advising practitioner can be found liable for any damages that the patient may suffer as a result of the negligent conduct. This is the case irrespective of whether or not the principal practitioner had discharged his or her duties owed to the patient by managing the patient appropriately or not.

Learning points

1. Always document any discussion you have with another colleague regarding a patient and include the salient points communicated to the clinician in the notes.

2. Always consider and document important positive findings as well as negative findings when formulating a diagnosis.

3. Liability can be attracted for physicians by offering subpar clinical advice on a patient’s management plan, even if you do not see the patient directly.