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Oh by the way, doctor

07 December 2015

Mrs R was a receptionist in a local estate agent’s office. One evening, she noticed that her 11-year-old son, Y, was limping as he walked towards her in the kitchen. Y was overweight and had been grumbling to his mother about his left knee hurting intermittently for the previous month.

On this occasion, when she asked why he was limping, Y told his mother he had slipped on ice in the playground earlier in the day. The fall had caused his leg to be sore. He had pointed at his thigh and said his knee was hurting again. The following day, Mrs R was booked to visit her GP, Dr G, to review her contraceptive medication. She decided to bring her son along with her, without an appointment.

At the end of her consultation, Mrs R asked the doctor if he would take a look at her son. She explained what had happened yesterday and told Dr G that Y had been limping at home. There was a computer record of the consultation with Mrs R, but not with Y. Mrs R reported that Dr G carried out a cursory examination of Y, while Y was sitting in the chair. She said that the doctor told them this was most likely a hip sprain, but to come back if the pain did not settle.

Dr G remembered Mrs R attending for a review of her medication, and then asking for her son to be seen at the same time. He recalled feeling rushed and that Mrs R was quite insistent that Y be examined. Dr G could not remember carrying out the examination and thought he had asked Mrs R to rebook an appointment for Y. As there was no formal record of this, there was therefore no note of such a request, or an examination being performed.

When they returned home, the boy continued to complain of pain in his leg. Mrs R decided to bring Y to the local Emergency Department (ED) three weeks later, where a doctor requested bilateral hip x-rays and subsequently diagnosed slipped upper femoral epiphysis (SUFE). The case was discussed with the orthopaedic team on call and Y was admitted immediately for internal fixation.

After his treatment, Y’s legs were of unequal length and one year later, he still walked with a persistent limp, which he found extremely distressing. The family had learnt it was likely that Y would require an early hip replacement in the future.

Mrs R made a claim against Dr G. As there were no records of the consultation, experts found it difficult to make a definitive assessment of the case, but they did find that Dr G’s management had not been appropriate. The case was settled for a high sum.

Learning points:

  • Remember the importance of contemporaneous record-keeping. Good documentation is the basis of good medical practice, and can help to defend a claim. Even if Y’s problem was mentioned by Mrs R as a “by-the-by”, Dr G should have made a clinical record of the events.
  • If you are going to assess a patient, even in someone else’s appointment, the history and examination should be carried out appropriately. Had Dr G done it at the time, he may have realised that there was a significant problem with the child’s leg. Otherwise, Dr G should have asked Mrs R to wait until the end of surgery for Y to be seen if urgent, or rebook an appointment for Y at a later date, when a more thorough history and examination could be carried out, if the problem could wait. Dr G should have made a record of this discussion.
  • A limp in a child can have multiple aetiologies: Perthes’ disease/trauma/transient synovitis/septic arthritis/osteomeylitis. Slipped upper femoral epiphysis usually affects boys aged 10-15 years old. Incidence is 1:100,000 and is bilateral in 20% of cases. It occurs more frequently in obese children with delayed secondary sexual development and tall thin boys.
  • Remember referred pain to the knee as an early clinical symptom of SUFE.
  • Examine both hips and check for restricted movement, particularly internal rotation.

Further information

  • Lalanda M, A limping Child, Casebook 15(2)
  • Lalanda M, Alonso JA, Improving the Management of the Child with an Unexplained Limp, Clinical Governance: An International Journal 11(4) 308–15 (2006)
  • Anthony S, Getting to Grips with Children's Hips, Casebook 12(3)
  • By Carrie on 21 June 2017 03:47 I would have offered to see, or have a colleague see, the boy at the end of all the booked appointments. As has been said, mum needed to accept some responsibility as she failed to book an appointment for her son (this is an expected level of parental care) and she then waited three weeks before taking him to A&E. Poor lad. And poor GP.
  • By Dr ZS on 22 May 2017 03:20

    This is a confusing case, dont know what would be the right answer here.

    The mother presented to ED 3 weeks after seeing the GP to discover a SUFE. If the GP asked the patient to book another appointment due to time restrictions (and documented this), the next available appt is probably in 3 weeks anyway, so what would be the outcome for the GP in this case? the mother could always say "the gp refused to see my son and told us to book an appt (which has a 3 week waiting list) and now he needs a hip replacement" etc.


    1: tell patient to come back - you miss something serious because the next appointment isnt for a few weeks

    2: quickly see the patient - miss something serious because you rushed

    3: properly see the patient - if you do this with every patient you will get stressed, and stress leads to youll miss something serious again

  • By Vicky on 03 October 2016 02:08

    NHS targets are unrealistic and put GPs under so much pressure, 10 minutes is not enough per appointment. the patient feels rushed and is then more likely to ask for additional problems to be addressed, as they dont know when they will be able to be seen again.

    I really feel for the medics in the UK, it is unfair for them to be bullied into a position of liability.

    The mother needed to take some responsibility for pushing the Dr to examine her son during her consultation.

  • By Al on 25 September 2016 11:21 Don't put yourself under the pressure, ask if has appt and if answer is no tell them it would be unfair to make my next patient who is on time wait, you really need to book an appointment 
  • By H Gallie on 17 April 2016 08:01 I do feel for the gp in this. In terms ofcovnitive processing the gp has closed the envounter attention is focused on whst needs To be done for the woman eg prescription/ documention. The mind is not "framed" for paediatric knee pain. I believe that thinking is not a recognised form of work, people dont realise we frame things in a context, have often read some notes prior to the encounter to prepare the mind. Default position would be make a seperate appointment.
  • By Dr Feras Tuma on 06 February 2016 03:29 This is so frustrating for us GP's and often the patient will say 'well I can not get another appointment' or 'I had to wait so long for this one etc' I think it is best to enter into the records "told to return for another appointment"
  • By Anjan Bose on 12 December 2015 10:00 i would agree this is a common occurrence but i will always enter the consultation on the computer as it takes only a few minutes to bring the notes up or as suggested ask the person to book an appointment and see the child as an extra at the end of the list-the parents will have to wait
  • By Dr ES GP on 23 May 2015 12:55 There by the grace of God go us all.....  This is a constant risk, the "By the way comment" when one is already snowed under with extras, running late, overworked and rushing to get to the next daily task. We are mere humans, we can't possibly get it right all of the time. An impossible situation which, sadly, is a common occurrence. 
  • By yusuf patel on 23 May 2015 12:29 i would normally ask them to book an appointment. Being rushed is not an excuse.
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