Case study - Expert evidence

...The patient alleges that Dr A's delay in making a referral allowed the tumour to progress from stage 1 to stage 2 but the expert disagrees...

BACKGROUND

MDDUS acting on behalf of a member commissions a report from an expert neurosurgeon – Ms P.

The case involves a 34-year-old salesman Mr K who, on attending his local surgery in Edinburgh, complained of episodes of faintness and a “bad taste in his mouth”, accompanied by a racing pulse. He also reported a history of epilepsy in the family. The GP member – Dr A – found nothing abnormal on examination, and in the patient notes he speculated on the possibility of reflux triggering the tachycardia. He prescribed omeprazole.

Two weeks later Mr K was back at the surgery with the same symptoms. Dr A ordered blood tests and arranged for a 24-hour ECG. Mr K attended for follow-up and still reported having periodic “dizzy” episodes, sometimes two or three times almost daily. He also reported feeling unfocused at work and being under significant stress. The 24-hour ECG and blood tests came back normal.

Mr K returned to the surgery two months later still suffering from dizzy spells with a racing pulse. He also reported feeling pins and needles in his right arm. Dr A ordered repeat blood tests but Mr K demanded a neurology referral.

A referral letter was sent from the practice to an outpatient clinic. Mr K was diagnosed with simple partial seizures and an MRI scan was arranged. This showed a tumour in the left temporal lobe, later identified as an astrocytoma grade 2.

Management options were discussed and Mr K opted to have the tumour excised. His future prognosis is uncertain as it was not possible to remove the entire tumour and recurrence remains a possibility.

A letter of claim was received by Dr A alleging clinical negligence in failing to make an urgent neurological referral when Mr K reported recurrent symptoms. It further alleges that the delay allowed the tumour to progress from stage 1 to stage 2, leading to a worse prognosis. Mr K has also suffered severe anxiety over the uncertainty caused by his symptoms.

ANALYSIS/OUTCOME

In order to prove clinical negligence a complaint must establish that there was both a breach of duty of care and also that this breach resulted in avoidable injury (causation).

MDDUS acting on behalf of Dr A commissions a report from an expert GP to provide an opinion on the alleged breach of duty of care. Ms P – as an expert neurosurgeon – is commissioned to consider causation in the case.

The expert GP is critical of Dr A’s record keeping in regard to the patient’s symptoms – noting a lack of basic details including frequency, duration and extent of the dizzy episodes over time. He also opines that Mr K’s recurrent symptoms at the time of the second consultation do suggest a diagnosis of simple or complex partial seizures and thus requiring a neurological referral. Not to do so could be considered a breach of duty of care.

Ms P in her report provides extensive background on the nature of gliomas, their staging and treatment options with associated prognosis. She advises that low-grade gliomas are usually managed conservatively by way of surveillance, but even immediate surgery around the time of the first consultation would not have made a difference to Mr K’s long-term prognosis, as (on the balance of probabilities) the tumour would still not have been completely resected given its diffuse nature.

Ms P also disputes the claim that the tumour progressed from grade 1 to grade 2 as a result of the delayed diagnosis. In her view a tumour of that size would have been present for years prior to onset of the simple partial seizures – given the slow growth of grade 2 astrocytomas.

A letter of response is sent to Mr K’s solicitors acknowledging breach of duty but asserting that clinical negligence is not proved, as causation has not been established – citing the report provided by Ms P.

Lack of causation in relation to the overall prognosis is later accepted by Mr K but he still maintains that there was clinical negligence in that the delay in diagnosis caused avoidable anxiety and suffering.

MDDUS, in agreement with Dr A, offers to settle in regard to this element of the claim.

KEY POINTS

  • Claims of clinical negligence require proof of both breach of duty of care and resulting injury and loss (causation).
  • Expert evidence is essential to establish whether there is a reasonable prospect of a case being proven should it go to court.