Case study: A painful twist

...An urgent referral should have led to an ultrasound scan in which the torsion would have been identified...

DAY 1

A 29-year-old male – Mr K – awakes on a Sunday morning with mild pain and swelling in his left testicle. An hour later the pain resolves only to recur later that morning, and this pattern is repeated throughout the day. Just before six he calls an out-of-hours service and is asked to attend a local clinic. Here he is seen by an OOH GP – Dr L. The patient describes his symptoms, which also include mild abdominal and back pain. Dr L examines the patient’s testicles and finds the left one is slightly swollen and tender, as is the epididymis. Both testes move freely. The scrotum skin is of normal colour with no rash or inflammation. Mr K informs the GP that two years ago he suffered a groin abscess with some swelling. Dr L advises the patient that he has an infection and prescribes co-amoxiclav – but as it is a Sunday he dispenses an immediate dose of amoxicillin. He also advises the patient to attend A&E if the pain/swelling increases and to contact his own GP for follow-up.

DAY 2

Mr K is still experiencing intermittent pain so he makes an emergency appointment with his regular GP. He again describes his symptoms and after another examination the GP refers him immediately to the local hospital with a letter requesting that testicular torsion be ruled out. Mr K drives to the hospital and sees an A&E triage nurse who advises that in view of his symptoms he should be seen by a consultant. He is directed to one of the wards for an ultrasound scan. Waiting over two hours the patient is told there is no staff available to conduct a scan and he is discharged home and told to wait for a phone call to come in when an appointment is available.

DAY 4

Early that morning Mr K awakes in “agony” with constant pain. A flatmate drives him to A&E and he undergoes an emergency scan. Later a consultant urologist informs him that the scan indicates that the blood supply has been cut off to the left testicle. Mr K undergoes emergency surgery but unfortunately the testicle is no longer viable and has to be removed.

 

OVER a year later Dr L receives a letter of claim from solicitors acting for Mr K. It alleges clinical negligence in the delayed diagnosis of the testicular torsion: this resulting in the loss of the patient’s left testicle with risk of fertility problems in future.

In particular the letter states that Dr L failed to refer the patient to A&E immediately on presentation at the OOH clinic. It says intermittent torsion should have been a serious consideration given Mr K’s symptoms and that the medical notes indicate the GP had considered the possibility – yet there is no reference to the GP having performed Prehn’s test to help determine whether the presenting pain was caused by acute epididymitis or from testicular torsion.

An urgent referral on that day should have led to an ultrasound scan in which the torsion would have been identified. Emergency surgery would then have resulted in the restoration of full blood supply and the testicle could have been saved.

MDDUS commissions a report from a primary care expert who examines the full medical records and various accounts from Dr L and others involved in the patient’s care. In his report the expert states that testicular pain is not a rare presentation and is most often due to infection or trauma but testicular torsion would be a routine differential diagnosis. He points out that the cause of testicular pain is not always clear but torsion is an important surgical emergency. The intermittent nature of the pain might have suggested infection was an unlikely cause and the referred abdominal and back pain (unless on micturition) could also have pointed to possible torsion. Reference by the patient to a past infection (i.e. groin abscess with swelling) could not be relied on without full medical records, which were unavailable to Dr L as an OOH doctor.

The expert acknowledges that Prehn’s test is not “fool proof” but that it would be reasonable to expect a GP to perform it and record the result. In his view this is the one clear failing in Dr L’s assessment of the patient.

On balance the expert concludes that Dr L was not in a position to sufficiently rule out torsion and it would have been prudent to refer the patient to a urologist as an emergency. The failure to do so was therefore negligent. However, he also questions the hospital delays which may have contributed to the poor outcome.

In the end MDDUS judges that the case against our member poses too great a risk to test in court and the decision is made to settle in agreement with the member and without admission of liability.

Key points

• Ensure you employ all routine assessments in consideration of common differential diagnoses.

• Relying on a patient’s recollection alone (without medical records) of previous conditions is risky.

• Record your justification for referral decisions.