Mrs S, a 27-year-old Romanian woman who lived with her husband in the UK, became pregnant and presented to her local GP surgery to commence antenatal care. Mrs S did not speak English and usually brought a family member with her to interpret. Mrs S presented to the emergency department at six weeks with vomiting and since she had previously suffered with a hydatidiform mole, an early scan was carried out, which confirmed a viable pregnancy. Mrs S received IV hydration and was discharged with oral cyclizine to use if the vomiting persisted.
A month later, she was feeling better. The vomiting had resolved and she was no longer using the cyclizine. She visited her GP Dr A, who noted “had Down’s scan, family member interpreter present, review at 16 weeks”. Mrs S visited Romania for a holiday to see her family. While she was there she presented to hospital complaining of possible kidney problems with a secondary concern over reduced foetal movements.
Mrs S underwent a pelvic ultrasound scan, which appeared to have shown a growth on her right kidney. Mrs S also claimed she underwent a triple test at this point.
After returning to the UK, Mrs S attended her routine 16-week check with Dr A. The practice antenatal template was completed and Dr A ticked that the Down’s screening test had been done. A month later, Mrs S was given the results of her Romanian triple test, which allegedly gave a risk of Down’s Syndrome of 1 in 67. Her combined test in the UK gave a much lower risk of 1:835. Based on her age, Mrs S had a background risk of 1:800 – therefore a risk of 1:67 would represent a significantly increased risk.
At 20 weeks, Mrs S presented to Dr A – her husband was present to translate but communication still presented a difficulty. Dr A documented that Mrs S had undergone an ultrasound in Romania that possibly showed a right kidney cyst. No reference was made to screening for Down’s Syndrome and Dr A asked the couple to return the following morning when a Romanian patient advocate would be present. There were no further entries made in the notes, but Dr A believed the advocate had spoken to him a few days later and confirmed Mrs S was concerned about the kidney cyst, which he advised could be explored further at her scheduled 20-week scan.
Mrs S reached term and gave birth to her son by emergency caesarean section due to fetal distress. The baby was born with Down’s Syndrome and patent ductus arteriosis and developed septicaemia and pulmonary hypertension.
Mrs S made a claim against Dr A, stating that she had been given false reassurance regarding her test results, which had also failed to be documented adequately in her notes. It was alleged that had she been referred to an obstetrician for amniocentesis, then she would have chosen to undergo a termination of pregnancy.
Expert Opinion
Expert GP Dr C maintained that Dr A’s standard of care did not fall below that expected of a GP. Dr C felt that Dr A was entitled to rely on the screening performed in the local secondary care setting, which indicated a low risk of Down’s Syndrome with no need for further investigations. Dr A’s account was that he was not told of the Romanian result, so was unable to take this into consideration. Dr C maintained that it would have been prudent to refer if this conflict had been made clear; however, even if this result had been available, given that it was carried out at 16 weeks – at a time when it would be less sensitive – it would have been reasonable for Dr A to have confidence in the local test carried out at the appropriate time.
Dr D, expert in feto-maternal medicine, stated that had Dr A been made aware of the test from Romania, it would have been a breach of duty to discount it. Assuming that Mrs S would have accepted the offer of amniocentesis, based on the timings, the diagnosis of Down’s would have been made between 22 and 24 weeks gestation, at which point a late termination of pregnancy could have been contemplated.
The case went to trial. Dr A proved to be a credible witness and set out his evidence well, which helped in the claim being dismissed.
Learning points
- Consultations with patients who do not speak the same language present a significant challenge for all healthcare professionals. If you cannot understand what a patient is saying to you then the consultation is inadequate, and you are putting both yourself and the patient at risk. It is important to try to use an interpreter rather than a family member if possible, unless a patient presents acutely.
- Patients who undergo investigations overseas often return home for ongoing care and this presents a challenge to GPs, as the validity of tests performed may be questioned. If in doubt, referral to a specialist may be the best course of action.