A catalogue of miscommunication - medical case study

The scenario below takes place over six years and involves the alleged failure of a GP and other healthcare professionals to arrange adequate follow-up after an abnormal cervical smear test.

Week one

A 35-year-old mother of four attends a local family planning clinic as she had been receiving intra-muscular injections of Depo Provera for contraception. A cervical smear taken at the clinic is reported as showing suspicious cells, and a note is made in the family planning clinic’s records that the smear should be repeated in three month’s time. A letter is sent to the general practitioner enclosing a copy of the cervical smear report, but indicating that this will be followed-up at the family planning clinic. No action is initiated by the GP at this stage.

Five months later

No further record appears in the family planning clinic notes until five months later when it is noted in the margin "C/S Please". A further note some two weeks later reads: "Unproductive domestic follow-up. Patient not in am and pm. Query letter to GP". A letter to the GP at that time indicates that the patient has not kept her appointment and that the clinic has been unable to follow her up at home. The letter concludes: "If you are seeing her and we can be of any further help we shall be pleased to see her again". The clinic also notifies the cervical cytology laboratory that it has been unable to repeat the patient’s cervical smear. No mention is made of further efforts to pursue the patient.

A nurse at the practice takes note of the failure of the patient to attend for a follow-up smear test and records this on the pink clinical continuation note sheet so that the next doctor to see the patient can advise her to attend a well women clinic to have a follow-up smear taken. No other action is taken by the practice after that entry.

One year later

The patient is now under the care of a consultant obstetrician and a smear is taken at an antenatal clinic and reported as 'suspicious'. A repeat smear is undertaken at the postnatal check and is reported as showing mildly atypical cells. No further records in the hospital case notes mention another smear being taken or any other follow-up arranged.

Four years later

No significant events are recorded (apart from missed appointments to the well woman clinic) until the patient attends the surgery four years later because of difficulties being experienced with an intra-uterine device. The GP has difficulty in replacing it and the patient is referred back to the family planning clinic. Unfortunately, the patient is reported as a new patient and no mention is made of the previous abnormal smear. The patient does not have a repeat smear taken as she is menstruating. She is invited to return to the clinic three months later but again fails to appear. A few months later the GP pays a home visit to the patient because of reported heavy vaginal bleeding. At this point she is referred to the hospital where carcinoma of the cervix is diagnosed leading to the need for radical surgery and radiotherapy. Solicitors acting for the patient launch a damages claim against the health authority and the GP.

Discussion 

MDDUS acts on behalf of the GP and commissions various expert reports. It is necessary to determine if the healthcare professionals involved demonstrated the skill and care of the ordinary competent professional, or did that care fall below standard?

The expert report commissioned by MDDUS takes the view that there was a distinct failure on the part of the family planning clinic to adequately inform the patient about the abnormal smear or to request follow-up by the general practitioner. The report also notes a failure in communication within the practice with the doctors not being alerted to the need for a repeat smear test. Nor was any action taken by the practice to inform the patient.

The case involves a catalogue of failures by the clinic, GP practice and hospital to take appropriate action on the possession of important information. The expert opinion concerning the hospital’s responsibility states: "This is not so much to do with medical negligence of an individual or a department, but an all round catalogue of communication problems and difficulties culminating in this very important and distressing situation ..."

The case was eventually settled and damages paid at around £100,000. A few weeks later the patient died.

Key points

Some important lessons can be drawn from this study:

• Ensure your practice has a robust, fail-safe system for ensuring patient follow-ups.
• Better to persist with reminders to patients rather than risk anyone slipping through the net.
• Assume responsibility for continuity of care to your own patients – other services may not act with the same diligence.

Alan Frame is risk adviser with MDDUS Training & Consultancy