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Over-managing error

30 September 2015

This case highlights why you should always raise queries or doubts with your supervisor.

Mr T, a 49-year-old mechanic, visited his GP with a list of problems and saw Dr R, a GP registrar. Mr T’s main concern was his persistent eczema in his left antecubital fossa. Dr R advised Mr T about the regular use of emollients.

Mr T was also concerned about intermittent groin strain after visiting the gym. He explained that the symptoms were easily controlled with rest and simple analgesia. Dr R enquired about any genitourinary symptoms. In their absence, Dr R felt able to reassure the patient and offered to see him in the future if the symptoms didn’t settle. Dr R also took the opportunity to check Mr T’s blood pressure, weight, BMI and smoking status.

Finally, Mr T mentioned that he had noticed a small amount of blood on the tissue paper when opening his bowels. Dr R noted that the patient had a variable bowel habit; however, Mr T’s stools had been looser than normal, although he did have occasional constipation. Mr T mentioned that he had been previously treated for piles, but hadn’t noticed any piles this time. He had felt a little tired recently, but this could be due to work. 

Dr R examined Mr T’s abdomen, noting that it was soft. A rectal examination revealed a small resolved pile, normal anal tone, smooth rectal wall and no blood on the glove. The prostate appeared smooth and non-tender.

Following the examination Dr R reassured the patient and outlined the warning signs that would need him to come back. Mr T felt very relieved as he had been concerned by the bleeding.

Dr R discussed the case with her trainer Dr B at the end of surgery, but didn’t document this discussion in the notes.

One year later Mr T returned to the GP surgery and saw Dr C. He outlined a long history of altered bowel function and a recurrence of fresh blood when opening his bowels. 

Examination of the abdomen and rectum was normal; however, in view of the long history and age of the patient, Dr C felt it appropriate to refer Mr T to general surgery via the fast-track cancer service.

Following colonoscopy, CT and MRI, Mr T was found to have rectal adenocarcinoma with multiple liver metastases. Mr T subsequently instigated a claim against Dr R and her supervisor Dr B.

Learning points, by Dr Richard Stacey, Medical Protection medicolegal adviser

  • When training, if you have any queries or doubts following a consultation make sure you discuss the matter further with your supervisor.
  • Document all patient related discussions with your supervisor in the patient notes.
  • When a patient has a list of symptoms, make sure you identify all the issues at the start of the consultation so you can prioritise your time.
  • Rectal bleeding is a common symptom – it is imperative that you enquire about and document red flag symptoms.
  • Make sure you are aware of NICE guidelines (referral guidelines for suspected cancer) and local fast-track cancer referral guidelines.
  • Ensure that you act in accordance with local and/or national guidance.
MPS publishes case reports as a risk management tool. The cases here are fictionalised, but are constructed from elements of real cases from MPS files, chosen because of their value as cautionary tales. They focus on mistakes, slips and oversights, which should alert you to common pitfalls encountered by junior doctors.

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