Caution sometimes best - medical case study

BACKGROUND: A 32-year-old woman – Mrs J – makes an emergency appointment at her GP surgery complaining of prolonged intermittent vaginal bleeding, abdominal cramps, sickness and diarrhoea. She is seen by a locum GP – Dr K.

Dr K records that the patient had stopped taking the contraceptive pill two months previous, planning to conceive. Her cycles have been irregular and she believes her last normal period was just over two weeks ago when the bleeding started. Mrs J is now wondering if there is any chance she might be having a miscarriage or an ectopic pregnancy. Dr K tells her that this is unlikely but advises the patient to try a home pregnancy test and phone back if positive.

Mrs J phones back later that afternoon and reports that the pregnancy test is indeed positive. Dr K asks her back into the surgery and examines the patient. He notes a “soft abdomen” with no tenderness. No vaginal examination is undertaken. A provisional diagnosis of threatened miscarriage is made and Mrs J is advised to rest and come back in if she has any problems with pain. A follow-up appointment is made for Mrs J to attend her regular GP who is then on holiday. The patient does not attend.

Two weeks later Mrs J appears at A&E one late evening complaining of severe abdominal pain and heavy bleeding. A transvaginal scan reveals a possible ectopic pregnancy. Her serum hCG level is raised and she is commenced on methotrexate to halt the pregnancy. The next day she is reassessed because of increasing pain and is taken to theatre for a laparoscopic left salpingectomy. Histology confirms an ectopic tubal pregnancy.

ANALYSIS/OUTCOME: Six months later Dr K receives a letter of claim alleging clinical negligence from solicitors acting for Mrs J. It states that the treatment by Dr K was substandard in that he should have organised an urgent referral to a hospital or clinic for further investigations that would have revealed the ectopic pregnancy. The letter further alleges that had Mrs J been referred on the day she attended the medical centre, the ectopic pregnancy would have been diagnosed and treatable with the agent methotrexate. In the over two-week delay her pregnancy had advanced such that surgical management was the only viable option.

Dr K contacts MDDUS and provides a response letter. He defends his decision not to refer stating that examination of the abdomen had revealed no tenderness. Neither were general abdominal pain or heavy bleeding features in the diagnosis – although this is contradicted by the letter of claim.

MDDUS commissions a medical report from a primary care expert who examines the patient notes and all other relevant records. He judges that Dr K should have considered the possibility of an ectopic pregnancy given the fact Mrs J had a positive pregnancy test and was having abdominal pain and irregular bleeding – also the patient had expressed an explicit concern.

Another report by a consultant obstetrician and gynaecologist confirms that had Mrs J been referred and diagnosed within two days of the initial presentation, her serum hCG levels would have been within the “success with methotrexate” range and – on the balance of probabilities – surgical intervention would not have been necessary.

MDDUS lawyers and advisers in discussion with Dr K decide it is best to settle the case with no admission of liability.

KEY POINTS

• Sometimes it is best to err on the side of caution when faced with a referral decision – especially with explicit patient concern.
• Provide clear instructions to patients on what action to take if symptoms change.