A recent blog from MDDUS risk adviser, Alan Frame, identified the most common area of claim in primary care as the diagnosis and investigation of presenting symptoms – accounting for 67 per cent of claims.
As part of our analysis of these cases, I am currently reviewing a GP claim centering around a missed diagnosis which highlights this all too clearly. Patient X was seen by a GP (Dr A) and a practice nurse within six months. The encounter with GP A and the handling of test results by a second GP (Dr B), have been criticised by our GP expert.
Dr A notes that Patient X is TATT – ‘tired all the time’. She requests a blood screen for fatigue but the patient never makes an appointment for the practice nurse to have the tests.
Consultation 2 / Handling of results (6 months later)
Patient X requests a consultation with the practice nurse. Blood tests are taken and the test results are returned electronically to Dr B’s inbox as Dr B is the patients registered GP. Dr B views the electronic result but files it without any action being recorded or required.
The results include a fasting blood glucose of 15.1mmol/L.
Patient X contacts the practice for the results of his blood tests and claims a receptionist informs him that ”there is nothing untoward to report”.
Three months after consultation 2, Patient X is admitted to hospital after experiencing chest pain. He is found to have had a myocardial infarction and is diagnosed with type 2 diabetes.
He raises a claim of clinical negligence, alleging that:
(1) In relation to consultation 1 - Dr A was negligent in her failure to ensure that the blood tests occurred.
(2) In relation to consultation 2 and the subsequent handling of results within the practice -
1. Patient X should have been notified of the blood results
2. the abnormal test results should have been acted on by Dr B (actions such as advising the patient they were likely to be diabetic, confirming the fact and starting to manage the condition)
3. action by Dr B would have avoided Patient X’s myocardial infarction
In the experience of MDDUS these circumstances commonly lead to medical negligence claims around missed or delayed diagnosis within primary care:
Requests for patient tests
Patient X did not attend for the tests requested by Dr A. Given the information available, there were no other flags about the level of capacity or clinical history of the patient. And so it is unlikely that Dr A would be expected to follow up this request, as it would be impractical to do so for every patient seen.
(If any warnings are present, it may be advisable to stress these to the patient, document that a higher level of risk is present and has been stressed, and in some circumstances ask for the patient to be followed up via a recall or diary system.)
Administration of patient tests & results
If the practice nurse had asked for the tests to be carried out in Dr A’s name, given that she had last seen the patient and requested the tests, Dr A may have recollected the patient and so may have had more ownership of any actions. This, however, is speculative and may work best for a patient whose case is well known to the GP.
It transpires that in this particular case Dr B was found to have ‘viewed’ the result electronically but for whatever reason – probably a momentary lapse in concentration – simply checked the result for filing and not action.
It could be argued that an electronic patient system – or indeed any agreed system of working for clinicians - which ‘forces’ action beyond simply ticking a box (e.g. a specific message to reception for the patient event if the result is marked as ‘file’), would have added a safety net here.
In addition, ensuring protected space and time for clinicians to undertake results reviews can assist in reducing human error.
Non-clinicians providing results to patients
Information given by receptionists to patients is reliant on the information provided to them by clinicians. Even if a test is ‘abnormal’, if the clinician has checked it for ‘file’ or ‘no action’ the receptionist may then reassure the patient that no further action is necessary. Of course, an abnormal test could be fine for that particular patient, but in this case it compounded the clinical error.
When working with complex systems, particularly those required to adapt to the needs of individualised patient care, there will always be room for human error and a requirement for MDDUS to support our members as well as compensating patients where acts of negligence have occurred.
I would be interested in hearing from GPs or practice managers willing to share good practice in this area.