Mr C, a 59-year-old self employed painter and decorator, visited his GP surgery complaining of a sore throat and change in his voice, which was a little hoarse. He was otherwise generally well. He had smoked approximately 15 cigarettes a day since his teens. At the initial consultation, Dr W diagnosed a viral upper respiratory tract infection and recommended simple analgesia with soluble paracetamol gargles.
Over a subsequent four-month period, Mr C attended on four further occasions. On each of these visits he saw the same GP, Dr W. The documentation of the visits was limited; on each subsequent occasion, Dr W diagnosed tonsillitis or a URTI. At the last of their consultations, Dr W noted that Mr C was “probably resistant to previous antibiotics” and prescribed a “stronger” antibiotic for a two week period. There was no record in the practice notes as to whether Dr W examined the throat and neck or questioned Mr C about any hoarseness.
On the next occasion he visited the surgery, Mr C saw a different GP, Dr M. Dr M recorded sore throat and hoarseness over a preceding period of several months; Dr M examined Mr C and found enlarged, immobile lymph nodes in the left side of Mr C’s neck. Dr M made an urgent referral to the local hospital ENT clinic, where Mr C was diagnosed with laryngeal cancer.
He required a laryngectomy and neck dissection of the lymph nodes with postoperative radiotherapy to his neck; Mr C was told the prognosis was poor. Soon after completing his outpatient radiotherapy, Mr C began a claim against Dr W.
The case was difficult to defend due to the poor clinical documentation. Mr C said that he was hoarse during his consultations with Dr W. However, there was no clinical record made by Dr W as to whether this was the case; the notes also held no record of whether Dr W had carried out any appropriate examination of the throat or recorded Mr C’s smoking habit. Dr W maintained that she had taken an appropriate history and carried out an examination of Mr C’s mouth and neck.
Primary care expert opinion was critical of Dr W’s poor record keeping and inability to substantiate and defend her care and management of Mr C’s persistent sore throat and hoarse voice. Any patient, particularly a heavy smoker, should be referred for an ENT opinion within three to four weeks if hoarseness or throat pain persists. The possible diagnoses include a primary laryngeal cancer or left vocal cord palsy due to lung cancer. In the opinion of an ENT expert, the delayed referral worsened Mr C’s prognosis and likelihood of cure. This claim could not be defended and the case was settled for a substantial sum.
- Good documentation is good practice, but also the basis of a good defence. If you examine a patient, record what you have done, what you have found (or not found) and what you concluded. Record your management plan, including follow-up arrangements. If there is a dispute between the memory of a patient and a doctor, where there is nothing in the medical records the courts are likely to prefer the patient’s recollection. See the case report on page 17 for more commentary on medical records.
- Hoarseness is an indication of a vocal cord symptom. If it is persistent or associated with other risk factors, early specialist referral is essential.
Robb PJ, Watson A, Hoarse Voice pp 149–56 in: ENT in Primary Care RILA Publications, London, UK (2008)