Blood in urine

BACKGROUND

A 49-year-old school teacher, Mrs D, attends her local out-of-hours primary care service late on a Saturday night having noticed blood clots in her urine.

She is seen by Dr T who records a two-day history of blood in the urine along with "cold-like" symptoms and feeling generally unwell. Mrs D also reports recurrent low-back pain over previous years.

Examination of the abdomen and back reveals nothing abnormal, and Dr T documents Mrs D's observation which are within normal limits. Urine testing is positive for blood (trace, +1), nitrites and white blood cells.

Dr T diagnoses urinary tract infection and prescribes a three-day course of nitrofurantoin. Mrs D is told to drink plenty of fluids and is given safety netting advice. She is advised to see her own GP if there is no improvement or the bleeding continues.

Mrs D receives no further follow-up and does not attend her GP surgery with ongoing symptoms.

Over two years later Mrs D attends her own GP reporting a four-day history of passing blood in her urine. She is referred to a urology clinic within the two-week wait system. An ultrasound shows a soft tissue mass on the right kidney. Mrs D undergoes a staging CT scan which reports a large renal tumour, along with small lung nodules and lymph node involvement.

The disease is stated as being incurable and Mrs D is offered palliative nephrectomy. A year later she dies from metastatic carcinoma.

A solicitor’s letter on behalf of Mrs D's family is received by the out-of-hours service relating to alleged negligent failure by Dr T to send an MSU (midstream urine) sample before prescribing antibiotic treatment. It is also alleged that Dr T failed to instruct Mrs D to consult her GP for a fresh urine sample after finishing the antibiotics – with the advice to consult her GP if "no improvement" being adequate.

The claim states that the delay in diagnosis allowed the tumour to grow and metastasise. Earlier discovery with a full or partial nephrectomy would on the balance of probabilities have been curative.

ANALYSIS/OUTCOME

An MDDUS adviser commissions expert reports from a GP with out-of-hours experience and a consultant urologist.

The GP reviews the case file and observes that Dr T saw Mrs D late on a Saturday night when the out-of-hours service would not have had access to laboratory testing of a MSU sample. The expert concludes that a provisional diagnosis of a urinary tract infection was appropriate given the urine dipstick analysis finding of blood, nitrites and white blood cells – and therefore a prescription for antibiotics was reasonable.

The GP also opines that it was reasonable for Dr T to advise Mrs D to see her own GP if symptoms persisted – and to assume that no further intervention would be required if the symptoms resolved with the course of antibiotics. The expert does observe that it might have been best practice to advise the patient to see her GP within the following two weeks irrespective of her symptoms – but he concludes that the care provided to Mrs D was reasonable and there was no breach of duty.

The consultant urologist comments on causation (whether there was harm as a consequence of the alleged breach of duty of care). She concludes that given the size of tumour and metastatic disease at diagnosis it is likely the tumour had been present at Mrs D’s consultation with Dr T at the out-of-hours centre. Extrapolation from the MRI findings at diagnosis suggests Stage T2a cancer at the first consultation, which would have required a full nephrectomy with a five-year survival rate of between 66 and 74 per cent.

A letter of response is drafted by an MDDUS solicitor based on the expert evidence. Breach of duty of care and causation are denied.

The letter further comments that Mrs D was clearly someone who took action when concerned about her health, having presented to an out-patient facility. She was clearly advised to attend her own GP if her symptoms did not resolve. Given she did not do so, it would be reasonable to conclude that Mrs D was suffering from a urinary tract infection that was resolved by the provision of antibiotics.

MDDUS is later notified that the case will no longer be pursued and Dr T is informed of the outcome.