Delayed liver disease diagnosis

BACKGROUND

Mr S is a 48-year-old administrator and attends his GP surgery feeling feverish, with right-sided pleuritic pain.

Dr J examines the patient and records a temperature of 39 and no obvious chest congestion, with a respiration rate of 14. He prescribes a dose of amoxicillin for a possible respiratory infection and advises Mr S to return in a week if his symptoms do not improve.

A week later Mr S re-attends the surgery. He reports having felt better after a few days but on going back to work the symptoms returned, with vomiting, stomach cramps and overall weakness. His temperature is normal but Dr J notes some epigastric tenderness on examination.

Dr J diagnoses excess gastric acidity leading to stomach irritation and prescribes a three-week course of omeprazole. He again advises Mr S to return if his symptoms do not improve.

Mr S is back at the surgery a week later still feeling generally unwell, with epigastric pain despite taking the omeprazole. Dr J records a normal temperature with some abdominal tenderness. He doubles the dose of omeprazole and arranges for Mr S to return for blood tests.

Five days later Mr S is driven to A&E by his partner and admitted to hospital with severe gut pain and intermittent rigors. An abdominal ultrasound scan reveals three echo areas within the right lobe of the liver.

Follow-up with a CT scan confirms the likely presence of liver abscesses. Mr S is commenced on antibiotics and subsequently diagnosed with primary sclerosing cholangitis (PSC).

A letter of claim from solicitors acting on behalf of Mr S is received by Dr J alleging clinical negligence in the delayed diagnosis of his liver condition.

ANALYSIS/OUTCOME

MDDUS reviews the case and commissions expert reports from a GP and consultant physician in hepatology.

The GP expert reviews the letter of claim, patient records and a detailed statement by Dr J. She concludes that in the first consultation the prescription of a course of antibiotics for a suspected chest infection, with a plan to review Mr S if not better, was reasonable and consistent with the care that would have been provided by a responsible body of GPs.

Considering the subsequent consultations, the GP expert concludes that Dr J’s assessment was adequate and prescription of a proton pump inhibitor (omeprazole) to reduce gastric acidity and improve stomach irritation was reasonable given the presentation of epigastric tenderness. Mr S was advised on both occasions to return to the surgery if there was no improvement or worsening of symptoms – and blood tests were ordered for further investigation.

The consultant physician comments on causation (the consequences of any breach of duty of care). He notes that the delay in the finding of liver abscesses between the first consultation and admission to hospital was about three weeks. The expert also speculates that the normal temperature recorded in later consultations was likely a result of the antibiotics prescribed for the suspected chest infection.

The expert points out that Mr S showed no early symptoms or signs of PSC, such as persistent jaundice, episodes of cholangitis or general abnormalities in liver function. This diagnosis was confirmed over a month later with magnetic resonance cholangiopancreatography (MRCP).

The expert concludes that had Dr J any cause to refer Mr S earlier over that three-week period it would have had no effect on the treatment or outcome of his condition.

MDDUS lawyers draft a detailed letter of response to the claim and it is subsequently dropped.