Conflicting scenarios

Mr P, 45 years old, attends his general practice complaining of epigastric pain after taking ibuprofen for cold sores. Dr A examines the patient and records “tender epigastrum but otherwise soft abdomen”. There is no bowel or bladder disturbance. The GP advises the patient that the pain will likely settle with an antacid but to come back if there is no improvement.

Two days later Mr P returns to the practice worrying he might have appendicitis. This time he sees Dr B who records “moderate epigastric pain following ingestion of ibuprofen, also vomiting”. On examination the patient has a tender upper abdomen but no guarding, with normal bowel sounds. Dr B makes a diagnosis of acute gastritis and prescribes omeprazole and metoclopramide. He advises Mr P again to return if there is no improvement.

Four days later Mr P returns to the practice. This time he is seen by Dr C who records pain now mainly in the right iliac fossa (RIF) with associated nausea, vomiting and diarrhoea. On examination the abdomen is tender over the RIF with rebound. Dr C refers the patient to A&E where CT confirms a diagnosis of acute appendicitis with appendicular abscess.

Mr P undergoes an exploratory laparotomy during which the necrotic appendix is debrided and the abdomen lavaged. A drain is inserted in the RIF prior to closure of the wound. After a prolonged hospital stay Mr P is discharged but later has to be readmitted with complications, adding to his pain and distress.

A few months later the surgery is notified of a claim of damages against Dr B for clinical negligence in failing to diagnosis and refer acute appendicitis.

Analysis and outcome

In the letter of claim Mr P presents a different version of the consultation with Dr B than that recorded in the notes. He claims on returning to the surgery the pain in his abdomen was so agonising he could “barely walk” and also that it had moved from the epigastric area to “just below the right side of my stomach”. Dr B disputes this account.

MDDUS commissions medico-legal reports from both an expert GP and a surgeon. The GP report finds that given the symptoms and signs recorded in Dr B’s consultation with Mr P it would not have been reasonable to refer the patient to a surgeon at that stage. But this opinion discounts the patient’s claim as to RIF pain and states in regard to the two conflicting accounts that it is “for the court to decide on issues of fact”.

The expert opinion of the surgeon confirms that had Mr P been referred to the hospital with RIF pain after his consultation with Dr B it is unlikely the appendix would have perforated. The patient would have required no more than a simple procedure followed by a relatively rapid recovery.

Presented with these reports Mr P and his solicitors are still determined to press ahead with the claim but indicate a willingness to settle. In the meantime Dr B grows increasingly stressed and worried over the case and is eventually signed off work. He is keen for a quick resolution.

MDDUS lawyers decide that on balance there is a risk in litigation that the court might give credence to the patient’s account of the consultation with Dr B and award significant damages along with legal costs. It is judged best for the Union and the member to pursue a modest settlement without admission of liability.

Key points 

• Early stage appendicitis is difficult to diagnose and can present with pain anywhere in the abdominal cavity but often localising to the RIF.
• Be sure to record any relevant negative signs on examination if there is any suspicion – i.e. 'no RIF pain'.
• Decisions to settle or legally contest claims are often judgement calls based on litigation risk.
• Members’ views are taken into account when deciding whether to settle a claim.