Wait and see? - medical case study

...contradictory claims over whether Mr L had reported vomiting while under treatment with oral antibiotics pose a significant risk...

MR L VISITS his local GP surgery complaining of feeling generally unwell with shooting pains in his neck and down his left side. A young locum GP examines the patient and diagnoses musculoskeletal pain for which he prescribes naproxen.

Over the next four days Mr L grows increasingly unwell. His wife phones the surgery and reports that her husband is suffering from fever and nausea along with shortness of breath and dizziness. He has also developed a dry cough. She reports the naproxen has done nothing to ease the pain which is made worse by breathing and the slightest movement.

One of the other GPs in the practice – Dr A – attends Mr L at home. On examination she finds that the patient has a temperature of 38.6 C and a pulse of 110/minute regular. On auscultation of the chest crepitations are heard at the left base. The patient also reports tenderness on palpation of the left lateral chest and in his left shoulder and arm.

Dr A diagnoses a chest infection and prescribes amoxicillin along with codeine for the pain. She advises Mr L to phone the surgery if his condition grows any worse.

Three days later Mrs L phones the surgery and Dr A again attends the patient at home. Mr L’s condition has not improved. His temperature is still elevated and he is suffering severe pleuritic pain on coughing. Dr A listens to his chest and notes crepitations and a possible rub on the left side.

In addition Mr L reports nausea and vomiting but this is not recorded in the notes. Dr A advises the patient that a trip to hospital might be necessary but Mr L is very resistant to the prospect. Again this discussion is not recorded in the notes. As the patient has shown no improvement the GP issues an alternative prescription for ciprofloxacin and also prochlorperazine for “dizziness” and arranges for a review in three days with consideration of a chest X-ray or bloods if no better.

Three days later Dr A again attends Mr L and finding no improvement arranges an urgent chest X-ray at the local hospital which reveals a left-sided severe pneumonia with pleural effusion and a likely empyema. Mr L is admitted to hospital and over 400 ml of fluid is aspirated and a chest drain inserted. Intravenous antibiotics and pain killers are administered but a few days later it is judged that surgical intervention is necessary as Mr L still has localised areas of pleural fluid trapped in the lungs. An open thoracotomy is undertaken with decortication of the pleura and Mr L is returned to the ward with two chest drains. Recovery is slow but uncomplicated and a week later he is discharged from hospital.

Six months later Dr A receives a notice of claim by solicitors representing Mr L. Among the allegations is a failure to urgently refer the patient to hospital for an X-ray after the second home visit when it was clear that his condition had deteriorated. Had Mr L been admitted then it is alleged he would have been started on intravenous antibiotics and on the balance of probabilities would have avoided developing empyema with the need for a thoracotomy.

Analysis and outcome

On behalf of Dr A MDDUS instructs a medical expert to write an opinion on the case. The expert examines the notes in regard to a number of issues. Mr L had claimed that Dr A was informed of his nausea and vomiting which if significant would have meant the prescription of oral antibiotics was inappropriate. But the notes make no mention of vomiting although it is significant that Dr A issues a prescription for prochlorperazine, which is commonly used to treat nausea and vomiting.

On the allegation of negligence in not arranging an urgent referral the expert concludes that Dr A would have had no valid reason to do so unless the patient was severely unwell and unable to “keep down” oral antibiotics. His view is that Mr L was treated in a manner appropriate with his symptoms and diagnosis. It is only after the expert has submitted his report that Dr A admits having discussed the possibility of hospital admission with Mr L.

MDDUS advisers and lawyers confer over the matter and decide that the contradictory claims over whether Mr L had reported vomiting while under treatment with oral antibiotics pose a significant risk if the case were to go to court. It is also felt that Dr A’s later statement that she had discussed the possibility of hospital with Mr L could be interpreted as a “de facto” admission that the situation had grown serious. It was decided to explore settling the case for a modest amount without any admission of liability.

Key points

  • Keep notes of all discussion with patients in order justify decisions made.
  • Consider if oral antibiotics are appropriate in any seriously unwell patient.
  • Err on the side of caution in any persistent infection.
  • Consider hospital admission if symptoms are deteriorating rather than improving as expected.