Case study: Earwax troubles

BACKGROUND

Mr L is 81 years old and attends his GP practice complaining of ear pain and hearing loss. Dr M examines both ears and notes a build-up of earwax in the auditory canals. She prescribes olive oil eardrops and advises the patient to avoid using ear buds. Mr L is told to return to the practice if symptoms do not improve.

A week later Mr L re-attends still suffering hearing loss and pain and “pressure” in both ears. Dr M finds that there is still significant impacted earwax in both canals. She prescribes sodium bicarbonate eardrops but a month later Mr M is back at the surgery with the same complaint and on this occasion Dr M doubles the dose of eardrops.

Two weeks later Mr L returns with his wife. Dr M examines the patient and again reports persistent wax build-up in the patient’s ear. Mrs L complains that the drops are obviously not working and asks why Dr M cannot syringe the ears. The GP explains that this is not a procedure carried out at the practice and offers to refer the patient to a local ENT clinic for auditory testing and earwax removal. In the meantime she prescribes more eardrops.

A few days later Mr L attends a local primary care walk-in centre complaining of persistent ear pain and hearing loss. He is seen by a nurse practitioner and referred for an appointment the next day at the ENT hub. An ENT nurse examines his ears and notes that the ear canal is clear of wax. She diagnoses bilateral otitis externa and is critical of the treatment that Mr L has received from the GP – in particular persistent use of sodium bicarbonate eardrops which has exacerbated inflammation in the ear canal. The nurse prescribes topical antibiotic eardrops, along with antibiotic tablets if there is no improvement after four days. Mr L is advised to attend either the clinic or his GP if symptoms persist.

Mr L attends a different GP at the surgery for follow-up and reports no more symptoms, but he and his wife are aggrieved at the delayed diagnosis/treatment and the weeks he was “left to suffer”. A few days later the practice receives a formal letter of complaint.

ANALYSIS/OUTCOME

The practice manager contacts MDDUS for advice on drafting a letter of response. A medico-legal adviser (MLA) offers guidance to Dr M in setting out her version of events. She is advised to address each of the concerns raised in the letter, including the reasoning behind her decision-making at the time – referencing any local or national guidelines. Dr L is also encouraged to address the criticism of her management plan made by the ENT nurse.

It is also suggested that Dr L provide a personal reflection on the matter, including what was done well and what could have been done differently. She is reminded that careful consideration of the complaint is not an admission of guilt but rather reassurance that the patient’s concerns have been taken seriously. Any learning points should be mentioned along with changes to practice implemented as a result.

A draft response incorporating Dr L’s statement is reviewed by the MLA. In the letter the practice expresses regret for Mr L’s dissatisfaction with treatment and offers to meet to discuss the matter further. It also reminds Mr L of his right to refer the matter to the ombudsman if he is still dissatisfied, and contact details are provided.

Mr L later phones to say that he is content with the practice response and considers the matter now closed.

KEY POINTS

• A comprehensive letter of response addressing patient concerns can often prevent a complaint escalating further into a legal claim or regulatory matter.
• Keep adequate notes justifying clinical decision making.