Case study: Earache assessed remotely

BACKGROUND

A six-year-old boy – Zach – awakes with an earache and discharge. His mother Mrs P phones the GP surgery and is told that a doctor will call back, as the practice is not offering routine face-to-face appointments due to Covid-19 risk. Later that morning, Dr J phones and Mrs P describes the symptoms and states that in the past Zach has been prescribed an antibiotic.

Dr J explains antibiotics are not usually offered for earache, as evidence shows that most children are unlikely to benefit. The GP advises symptomatic treatment with paracetamol and ibuprofen. Mrs P is told to contact the surgery if Zach’s symptoms worsen rapidly/significantly or do not improve after three days, or if he becomes generally unwell.

Zach’s earache persists over the next three days and Mrs P phones the surgery again. She reports a thick yellow discharge from the ear with some blood and suggests that the GP might want to examine Zach, as she is worried about the possibility of mastoiditis.

Dr J phones back and in discussion with Mrs P ascertains that Zach has no signs of systemic illness, such as an elevated temperature, and is eating and drinking as normal. He prescribes a course of amoxycillin and reassures Mrs P that acute complications such as mastoiditis are rare, with or without antibiotics.

Dr J also tells Mrs P there is no need to see Zach as this would not change the treatment being offered. She is again advised to contact the surgery if Zach’s symptoms do not improve.

Three days later Mrs P phones NHS24 late at night when Zach’s pain appears to worsen and she is advised to take him to a local out-of-hours clinic. He is prescribed co-amoxiclav and the infection resolves over the next week.

The practice receives an angry letter of complaint from Mrs P. She states that had Zach been examined initially and offered an antibiotic he would have been spared a week of pain and anguish.

ANALYSIS/OUTCOME

The practice manager contacts MDDUS for advice on the draft complaint response. The letter first offers an expression of regret at the pain suffered by Zach and also for Mrs P’s dissatisfaction with the care provided by the practice. It then addresses the treatment provided by Dr J, citing (in lay terms) NICE guidance on the management of otitis media, including recommended indications for first and second-line antibiotic treatment.

A clear explanation is then provided of current practice policy regarding telephone triage and the selected use of remote consultations given the present Covid-19 risk. Mrs P is referred to the practice website which provides further details.

An offer is made to discuss the matter and Mrs P is reminded of her right to refer concerns to the ombudsman (address provided) should she remain dissatisfied. Nothing further is heard from Mrs P on the matter.

KEY POINTS

• Consult relevant clinical guidelines when managing otitis media in children, particularly indications for antibiotic prescribing.
• In remote consulting, take time to establish the needs of the patient and to ensure advice is understood.
• Keep adequate records of all information given to the patient, including guidance on prescribed medication and safety netting advice.
• Ensure your practice website provides a clear explanation of practice policies/procedures in response to government guidelines on Covid-19 risk.