Missed follow-up

...The patient attended her practice for various reasons over the course of six years. But no follow-up action was taken on the abnormal test result...

Mrs B attended her local practice with a chronic headache and unexplained weight gain. Blood tests were arranged including thyroid function and her thyroxine level was found to be within normal limits but her TSH was slightly elevated. No follow-up action was taken on this result even when the patient presented again later in the year with a respiratory infection.

Mrs B attended the practice for various reasons over the next 6 years and in one consultation the GP noted that her weight had further increased and advised Mrs B to go on a diet. But on no occasion was there reference again to the elevated TSH level.

Six years after the initial consultation Mrs B again attended the practice complaining that she kept getting colds and "felt low". More blood tests were ordered by the attending GP including thyroid function, and her TSH was again found to be elevated. A note on the results form read – "mild hypothyroidism" – and an action stamp was applied to the back of the form indicating the test should be repeated in 2 months. There was no record in the notes of the abnormal test result being communicated to Mrs B nor was there any follow-up.

Mrs B presented at the practice three years later with a bilateral goitre. Blood tests revealed a seriously elevated TSH level and the GP initiated treatment with thyroxine. The patient was referred to a surgical clinic. Later that year she underwent a total thyroidectomy to remove the goitre. The operation proved difficult and damage occurred to the recurrent laryngeal nerve, causing paralysis of the right vocal cord. Mrs B needed speech therapy to regain limited use of her voice and had to give up her job as a result of the complication.

Upon learning of the original abnormal thyroid function test and the lack of any follow-up or subsequent treatment Mrs B contacted her solicitors and a letter of claim was received by the practice.

Analysis and outcome

The claim alleged that the practice was negligent in failing to follow-up on the two abnormal tests and monitor Mrs B’s TSH levels such that treatment could have been initiated at a reasonable stage. It was argued that had Mrs B been started on T4 replacement the goitre development might have been arrested and surgery, on that particular instance, would not have been necessary. Negligence was not alleged in the nerve damage during the surgical procedure – only that the operation should have been avoided.

The GPs involved admitted liability and the case was settled for a substantial amount. The practice has since conducted a full review of its records procedures in regard to laboratory results handling to ensure that such system failures are not repeated.

Key points

  • Ensure robust systems for flagging abnormal results for review.
  • Make sure that abnormal results are communicated to patients with a full explanation of significance and a treatment plan.