Haematuria noted - medical case study

BACKGROUND: A 48-year-old patient – Mr P – attends his local surgery with a two-day history of urinary tract symptoms: frequency and urgency. His GP – Dr K – examines the patient and finds: “No palpable bladder, apyrexial, urine cloudy with mucous. Test positive for blood, protein, leucocytes.” The GP also notes that Mr P has had a history of bladder outflow problems in childhood for which he had surgery.

Dr K diagnoses urinary tract infection (UTI) and prescribes the antibiotic trimethoprim. Urine culture later confirms the infection. Two days later Mr P phones the surgery and speaks to Dr K reporting an improvement in symptoms but that he feels intermittent blockage and that his urine is still cloudy. Dr K makes a routine non-urgent referral for Mr P to an urology outpatient clinic.

Two months later Mr P is seen at the outpatient clinic. He again complains of persistent frequency and urgency. A staff grade physician measures flow rate and performs an ultrasound scan to assess bladder emptying. This reveals no abnormality and no further investigations are undertaken.

A week later the patient requests an emergency appointment at the surgery and sees a different GP. He has blood in his urine but the GP notes that the patient was only just recently assessed and given an all-clear. Mr P is prescribed more antibiotics and told to present a urine sample in 10 days.

Later that week Mr P makes another appointment at the surgery and sees Dr K. The GP notes that the patient is passing urine 20-30 times per day and with significant difficulty. He is also passing blood. Dr K makes an urgent referral under the two-week cancer rule and records in the referral letter that the patient has both white and red blood cells present in his urine.

Four days later Mr P is seen at the urology clinic. An SPR arranges for an ultrasound and cystocopy to investigate the cause of the patient’s recurrent UTI. The tests reveal a bladder cancer invading muscle. A CT scan shows that Mr P already has metastatic disease. A transurethral resection is carried out and chemotherapy organised with an oncologist. The patient fails to respond to treatment and dies three months later.

Six months later a letter arrives from solicitors acting on behalf of Mr P’s family alleging clinical negligence against Dr K for not referring the patient for urgent investigation after the initial consultation. This would have allowed diagnosis and treatment of the carcinoma before it metastasised.

ANALYSIS AND OUTCOME: Dr K contacts MDDUS and expert opinions are commissioned from both a primary care physician and a consultant urologist.

In the letter of claim it's alleged that Mr P had complained of frank haematuria with clotting but this is not reflected in Dr K’s notes – and it is on the basis of the recorded observations that the GP made a non-urgent referral in the initial consultation. The diagnosis of UTI was confirmed by culture and the GP’s judgment was further supported by the fact no abnormality was noted when Mr P was eventually seen in the outpatient clinic. The primary care expert offers the opinion that a competent GP acting with reasonable care would have managed the patient in a similar way to Dr K.

The urologist is of the same opinion that Mr P’s symptoms at the initial consultation with Dr K were consistent with UTI. However, he is critical of the attending physician at the first outpatient consultation. In his opinion standard practice with symptoms of urgency would have warranted a cystoscopy to rule out bladder pathology.

In the question of possible causation the urologist states that even had the tumour being diagnosed in an urgent referral after the first consultation it is likely there was already metastatic disease present. MDDUS solicitors offer a denial of liability and rebuttal of causation. No further action is pursued by the claimant.

KEY POINTS

• Clear and comprehensive records are key in defending negligence claims.
• More than one positive test result for haematuria merits further investigation.
• Recurrent urinary tract infection is a red flag, especially in men.