Unresolved infection - medical case study

...the GP diagnoses mastitis and prescribes amoxicillin...

BACKGROUND: Mrs G attends her local GP surgery with a warm/painful left breast. She had given birth to her daughter three weeks previous and is breast feeding.

Dr B examines the breast and makes a diagnosis of mastitis. A prescription for amoxicillin is issued and Mrs G is advised to continue breast feeding.

Seven days later Mrs G phones the practice having completed the full course of antibiotics. She tells the receptionist the discomfort in her breast has grown worse. No appointments are available that day and the receptionist tells Mrs G that it is not possible for her to speak directly with a doctor but says she will have a word with Dr B and phone back. A further prescription for amoxicillin is then issued which Mrs G collects from the surgery.

Three days later Mrs G attends the local out-of-hours service and is examined by the GP on-call. He notes that the mastitis is worse, showing erythema and swelling, with a broader area of induration. It is warm and tender to touch. The GP changes Mrs G’s medication to flucloxacillin and advises her to return if there is no improvement.

A day later Mrs G returns to the out-of-hours clinic complaining that the swelling in her breast has “burst” with blood and pus coming out. The attending GP notes: Lt breast inner quadrant red/indurated. Swollen/tender & 2 inches from areola burst opening, now closed. Consult surgical SHO.

Mrs G is sent to the local A&E and admitted to hospital. One day later she undergoes surgical incision and drainage of the abscess. The wound requires regular dressings and is slow to heal.

Six months later the practice receives a letter from solicitors representing Mrs G alleging clinical negligence against Dr B. Among the specific allegations is breach of duty in failing to identify that mastitis is usually caused by a penicillin-resistant staphylococcus and thus amoxicillin was an inappropriate choice of antibiotic. The letter further states that Dr B should have called Mrs G in for review or arranged for her to be attended at home before issuing the repeat prescription for amoxicillin.

It is further alleged that had Mrs G been given the appropriate treatment on first attending Dr B the mastitis would have resolved without progressing to an abscess, leading to hospitalisation and a long recovery with residual scarring and tenderness.

ANALYSIS/OUTCOME: Dr B contacts an MDDUS adviser and provides an account of his treatment of Mrs G. A report commissioned from an expert in primary care medicine is critical of Dr B's actions in the case. The expert cites clinical guidelines stating that the recommended treatment for unresolved mastitis is flucloxacillin or erythromycin – the rationale being that mastitis is most frequently caused by a penicillin-resistant staphylococcal infection.

The expert is also critical of the failure to re-assess Mrs G’s condition before issuing the repeat prescription.

In terms of causation the expert offers the opinion that had the patient been given an appropriate antibiotic at the initial consultation the mastitis would have resolved and there would have been no need for later hospitalisation and surgical treatment.

Having considered the expert report and discussed the case again with Dr B, MDDUS contacts the patient’s solicitors and offers a modest settlement which is accepted.

KEY POINTS

  • Keep up to date with latest clinical guidelines.
  • Ensure repeat prescriptions are not simply a matter of routine.
  • Ensure practice appointment systems do not act as a bar to potential emergencies.

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