Case study - A painful leg

DAY ONE

A 72-year-old woman – Mrs T – attends her GP surgery complaining of right leg pain of about nine days duration felt mainly on walking. In addition she suffers from occasional dizziness but has no chest pain or dyspnoea. Her regular GP – Dr L – examines Mrs T and finds her heart rate is 150 beats per minute and blood pressure is 160/88. He notes a weak left femoral pulse but a good pulse on the right. No pulses are felt below this level on either leg. He also notes that the right foot is rather colder than the left.

Dr L makes a diagnosis of right popliteal thrombosis and raises the possibility of paroxysmal sinus tachycardia. He refers Mrs T to the local hospital and here she is examined by an SHO who notes in summary: “Painful right leg but good pulses and perfusion. No DVT clinically. ECG shows only left ventricular strain. No further investigation or treatment initiated”. Mrs T is discharged home.

DAY 23

Mrs T is driven by her husband to the A&E department of the hospital. She tells the attending doctor that her leg is bothering her day and night – keeping her awake. He examines her and notes: “Nil to find. Painful right leg. No DVT.” She is sent home with a Tubigrip.

DAY 31

Another GP with the practice – Dr D – is called out to visit Mrs T at home. Her husband tells the receptionist that his wife is complaining her leg “feels a ton weight” and it looks cold and white. Dr D undertakes a quick examination and records “Feet healthy. Pulses fine.” She diagnoses right-leg sciatica aggravated by a shortened left leg from a previous hip fracture and prescribes a painkiller.

DAY 36 AND BEYOND

Mrs T arrives again at A&E with severe constant pain in her right calf and thigh. The right foot is found to be cold and cyanosed with a diminished arterial pulse. The attending doctor makes a diagnosis of critical ischaemia with impaired circulation due to a right femoral embolus. The patient is placed immediately on intravenous heparin. Six days later she undergoes a right femoral bypass operation followed in a few days by a right popliteal graft embolectomy. Sadly these procedures prove unsuccessful and the only viable option is an above-knee amputation.

Six months later intimations are made by solicitors on behalf of Mrs T alleging clinical negligence against the GPs and hospital doctors involved in her care.

THE second GP in the case – Dr D – is an MDDUS member and she forwards a copy of a letter from Mrs T’s solicitors in which they allege she failed (at the home visit on Day 31) to take a full and accurate history, carry out an adequate examination and subsequently to refer the patient promptly for specialist treatment on the basis of the symptoms exhibited.

Numerous reports are prepared in regard to the case from medical experts both in primary and specialist secondary (vascular) care. All are in agreement that the first GP, Dr L, acted correctly in referring Mrs T to hospital with suspected popliteal thrombosis. But it was judged that the patient’s care in A&E on both occasions was below reasonable expected standards with no relevant investigations carried out in regard to a clear risk of impaired arterial circulation.

The experts also criticise Dr D’s treatment of the patient stating that she dismissed the findings of her colleague Dr L without sufficient consideration – possibly on the basis of the hospital reports. Going by the patient’s records, Dr D did not appear to take an appropriate history apart from noting the five weeks of pain/numbness. She mentioned taking pulses but not which, or what was meant by “Feet healthy”. No details were recorded in the notes of Dr D doing a neurological examination – straight leg raising, nature and site of pain – sufficient to justify a diagnosis of right-side sciatica.

An expert vascular surgeon commenting on the case judges that the delay between Dr D’s examination and Mrs T’s subsequent diagnosis of critical ischaemia resulted in “progressive deterioration of the status of the leg”. He states: “Femoral-popliteal bypass grafts performed before a limb reaches the stage of critical ischaemia have a 70-80 per cent probability of being successful. With delay the prospects of successful arterial repair progressively diminish.”

Six months later Mrs T suffers a stroke and dies and her husband instructs the solicitors to abandon the claim.

Key points

• Ensure that you justify clinical judgments in the patient’s notes especially if at odds with earlier decisions or diagnoses.
• Make complete records of all examinations undertaken.
• Ensure the notes record not only a diagnosis but the reasoning behind that diagnosis.