By Dr Sean Kavanagh
Mr Y, a 24-year-old plumber, had suffered intermittent bouts of cramping abdominal pain with associated passage of loose stools, mucus and occasional small amounts of fresh red blood, over a period of two months.
His GP, Dr D, referred him to Dr B, a consultant gastroenterologist. Dr B saw Mr Y in clinic and arranged to carry out an outpatient colonoscopy. Dr B managed to pass the scope as far as the splenic flexure, but was unable to progress any further due to difficult anatomy and the pain that the procedure was causing Mr Y. The colonoscopy was terminated. The appearance of the colonic mucosa up to the furthest point reached had been normal.
By the time of the procedure Mr Y’s symptoms had settled so Dr B reported the colonoscopic findings and the technical difficulties to Dr D, and discharged Mr Y back to his care.
Unfortunately Mr Y’s symptoms returned a few months later. He repeatedly attended Dr D’s surgery over a six-month period, with increasingly severe symptoms. Dr D treated Mr Y with PRN loperamide and diazepam as he felt that the symptoms may have been due to anxiety associated with Mr Y having recently lost his job for frequent non-attendance due to illness.
One night Mr Y woke in excruciating pain and was admitted to hospital with an acute abdomen caused by colonic perforation secondary to acute ulcerative colitis. He underwent laparotomy and repair and made a good recovery on conventional medical therapy.
Mr Y made a claim against both Drs D and B, alleging negligence in failing to make a timely diagnosis, causing him to lose his employment and endangering his life through the complications of the missed diagnosis.
The Medical Protection legal team commissioned an expert in gastroenterology, who felt that Dr B had done all that could be expected of him, given the well documented technical difficulties in performing the colonoscopy, and as Mr Y was asymptomatic at the time. It was held that in this context the risk of perforation due to over-zealous passage of an obstructed colonoscope outweighed the benefits of pressing on with the procedure.
Dr B’s letter to Dr D had clearly advised that should Mr Y’s symptoms recur it would be advisable to repeat the procedure or consider other forms of investigation. On this basis we elected to defend Dr B and he was eventually dropped from the legal action. The case was settled out of court for a moderate sum on behalf of Dr D.
- If diagnostic investigations have to be curtailed for technical reasons, best practice dictates that clear reasons for abandoning the procedure should be documented in the medical record.
- It is important to consider whether alternative investigations or a repeat attempt are necessary after having to abandon an investigation. In this situation, the patient was asymptomatic, but in such a scenario, advice to the referring doctor on what to do if the problem recurs is essential.
- GPs should have a low threshold for asking for further advice where there is an inconclusive or abandoned specialist investigation, but ongoing or worsening symptoms.