Medical Protection litigation solicitor Suzanne Tate looks at a claim involving a missed diagnosis of sepsis and the work of Medical Protection in successfully defending seven GP members
The case
Ms N was a 33-year-old mother of two children. Ms N had been unwell for two weeks suffering from a cough, cold and sore throat. She had attended her GP practice a number of times and had been treated for pharyngitis and an ear infection.
After this two-week period Ms N continued to feel ill and then developed a hand injury and swollen wrist after falling on it. She was seen at a minor injuries unit (MIU) by a nurse practitioner, who found Ms N’s left hand to be grossly swollen, red and inflamed, tender to touch and with a reduced range of movement. Ms N’s wrist was x-rayed and no bony injury was found. However, the nurse practitioner recorded Ms N had a pulse of 160, blood pressure 120/55, a respiratory rate of 19 and a temperature of 40.5 C.
The nurse practitioner advised Ms N and her partner, Mr Q, that she should see her GP that day.
Ms N and her partner drove straight to their GP practice where all seven partners were Medical Protection members. They arrived at around 11.55am, but the surgery was due to close at 12pm for a protected learning time initiative. Ms N felt too ill and stayed in the car. She never entered the practice. Mr Q was told by a receptionist there were no available appointments that afternoon – and that he should contact 111 to access a GP appointment out of hours, go to the Emergency Department, or contact 999 for emergencies. Alternatively, he could also return again in the morning when the practice reopened for an appointment.
Ms N returned home with her husband and they did not contact 111 or 999.
The following morning, Ms N saw a GP at the practice who noted she was very unwell, with some swelling to the left hand, swelling to the whole of the right arm and hand, with bruising and discolouration to the skin. The GP immediately requested an ambulance for Ms N, but Mr Q thought he could drive Ms N to the hospital quicker and they set off immediately. On arrival Mr Q found a wheelchair and took Ms N to the Emergency Department reception, reporting that her GP had urgently referred her, and they were asked to wait. He left Ms N briefly in the reception area to park his car, but when he returned she had suffered a cardiac arrest, unnoticed by emergency staff. Ms N was resuscitated but suffered a second cardiac arrest and died later that afternoon.
The cause of death was later confirmed as streptococcal toxic shock syndrome. At the inquest into Ms N’s death it was determined that if she had been referred to hospital at any time on the first day, it is likely she would have survived.
What happened next
At the inquest, the coroner gave a Regulation 28 Report to Prevent Future Deaths to the practice and the local CCG. The coroner’s view was that the issues should also be addressed nationally. Whilst it was found by the coroner to be correct and appropriate for GP practices to have dedicated time for staff training, the coroner requested the practice and CCG take action to ensure these training times are advertised well in advance, with clear and specific instructions provided for patients to seek treatment elsewhere. Furthermore, on occasions where there is a genuine emergency, a doctor should be available, notwithstanding the surgery being closed for routine work.
NHS England served the practice with a breach of contract notice. This was for failing to ensure any patient who has not previously made an appointment, and who attends the practice premises during normal hours (8am-6.30pm Monday to Friday) for essential services, is provided with such services by an appropriate healthcare professional.
Medical Protection was not made aware at the time of the breach of contract notice. This could have been appealed on the basis that the practice was taking part in a training initiative supported by the local CCG. It would therefore have been appropriate for Ms N to be referred elsewhere (111) for essential services while the practice was closed for protected learning time.
The claim
Several months later, Mr Q pursued a negligence claim against the MIU and against the seven GP members. The practice notified Medical Protection and we denied liability on their behalf with supportive expert evidence.
The MIU denied breach of duty and blamed the GP practice.
Medical Protection maintained the practice did not have a duty of care to Ms N merely by virtue of her partner attending at the practice. The practice had never assumed responsibility for her: they had confirmed they could not treat her at the practice that afternoon and correctly directed her to the right pathway to access triage and treatment (111).
We maintained a court could not conclude that the practice was acting negligently in undertaking training and being closed for the afternoon. It was appropriate for the practice to subcontract out its obligations to NHS England by the use of an out of hours GP.
Medical Protection continued to deny liability on behalf of the practice and were very cautious that any admissions or offer to settle the claim on behalf of the practice could have set a worrying precedent that practices owe a duty to everyone who sets foot on the premises.
The outcome
The MIU agreed a sum for damages with Mr Q and the claim was discontinued in full against the practice.
Commentary
It is clear opportunities were missed to avoid the tragic outcome in this case.
Experts did not consider the nurse practitioner at the MIU ought to have been able to make a diagnosis of sepsis, but her observations indicated a number of clear signs of systemic infection. In those circumstances, she chose an incorrect pathway to refer Ms N to her GP that day, without first calling the practice to confirm if an appointment was available or that the practice was even open. Her recorded observations were not available to the practice until they were sent across by a batch transfer system later in the afternoon when the practice was closed. An alternative pathway for Ms N, in view of her recorded observations, would have been to refer her immediately to the Emergency Department. It seems there was also a failure to emphasise to Ms N the importance of being seen that day and what she should do if a GP appointment was not available.
There was perhaps another opportunity missed by the receptionist who could have advised Mr Q that he should still contact 111, even if he had spoken with them in the morning, since the circumstances had changed since his last call.