Infected rash

A 42-year-old patient, Mrs H, attends her GP surgery complaining of a painful skin rash on her inner thigh. She is clinically obese and suffers from asthma. Dr J undertakes an examination with a chaperone and records a diagnosis of macerated intertrigo. He decides against topical treatment in order to keep the rash dry and prescribes an oral antifungal.

Mrs H is advised to return if the rash shows no improvement.

Two weeks later Mrs H attends the surgery as her rash is ongoing. She is seen again by Dr J. Examination reveals the rash is now less macerated but still red and inflamed. Mrs H also reports a flare up of her asthma, with mucoid sputum and a chesty cough and wheeze.

Dr J prescribes an antifungal cream for the rash and oral prednisolone for her asthma.

Five days later Mrs H attends an emergency appointment at the surgery with her husband. She has developed an abscess at the site of the rash. Dr J undertakes an examination and records: Large draining abscess with surrounding cellulitis. Temp: 38.1, pulse 105. He prescribes flucloxacillin four times daily for a week and instructs Mrs H to return in five days for review.

Early the next morning Mrs H becomes very unwell and has severe pain in her leg. She is brought to A&E and assessed by the on-call registrar. The registrar records: abscess left groin with apparent discharge and cellulitis; 6 cm lump. Temp 39.4, pulse 126, BP 85/40, white count: 21.4. Mrs H is admitted to hospital and sepsis protocol is initiated. She is started on IV co-amoxiclav and referred for surgical review.

She undergoes emergency tissue debridement revealing necrotising fasciitis affecting skin and subcutaneous tissue. The infection responds well to surgery and antibiotics and Mrs H spends two weeks in hospital before being discharged.

A letter of claim is sent to Dr J by solicitors representing Mrs H, alleging clinical negligence in her care. It claimed that referring Mrs H immediately to hospital for IV antibiotic treatment and drainage of the abscess would have avoided the need for more extensive surgery.

ANALYSIS/OUTCOME

An MDDUS solicitor acting on behalf of Dr J reviews the case and commissions expert reports from a GP and a consultant surgeon.

The GP expert is not supportive of Dr J’s treatment in the case. She observes that it would be usual practice to organise incision and drainage of a large skin abscess, as recommended by NICE.

The expert also observes that further NICE guidance would recommend admission for IV antibiotics in a patient who has acute cellulitis and is systemically unwell or immunocompromised. The only observations documented by Dr J are the pulse and temperature, however these were both elevated and Mrs H had visible cellulitis as noted by Dr J. She was also taking prednisolone for her asthma, which is an immunosuppressant. There is no indication that Dr J considered hospital admission for Mrs H, or that the potential severity of her condition was discussed.

The GP expert concludes that Dr J’s failure to refer Mrs H for emergency treatment of the abscess constitutes a breach of duty of care.

An expert consultant surgeon is asked to comment on causation (whether there was harm as a consequence of the breach of duty of care). Had Mrs H been referred immediately to A&E after presenting with the abscess would that have had a material effect on the outcome?

The surgeon concludes that with immediate referral Mrs H would have been admitted for surgical review. A CT scan that afternoon/evening would have likely revealed gas in subcutaneous tissue indicating necrotising fasciitis. Emergency surgery would have been indicated for this life-threating condition and this would have been carried out at least 14 hours earlier.

The expert estimates that avoiding this delay would not have prevented the necessary surgery but there would have been a 10 to 15 per cent reduction in the area and extent of infection and thus subsequent debridement and recovery time.

Given the unsupportive reports on both breach of duty of care and causation, MDDUS, in agreement with Dr J, decides to settle the case out of court. Dr J was disappointed to learn that the experts did not support his management, but accepted the position and was grateful for the support he received from MDDUS.