Ms D, a 60-year-old woman, underwent a total hip replacement under the care of consultant orthopaedic surgeon Dr R.

She recovered well from the surgery, however her routine postoperative blood tests were slightly abnormal. She was discharged on day 3 post-procedure and was advised by the resident medical officer, Dr B, to see her GP for follow-up blood tests. The abnormal results were not communicated to the consultant in charge, nor was it documented on Ms D’s discharge summary.

Four days after her discharge, Ms D attended her GP requesting an appointment as she was advised that she needed blood tests. This was booked in for two weeks later, as there had been no indication of how urgently these needed to be done.

Twelve days after she had been discharged, Ms D felt unwell and attended the Emergency Department. She was admitted to intensive care and sadly died three days later.

An inquest took place. Witness statements were obtained from the staff involved. Dr B recalled verbally advising Ms D that she should see her GP for follow-up blood tests. He requested that this instruction be entered into Ms D’s discharge letter. However, he did not prepare the letter, nor did he review it prior to it being sent to Ms D’s GP. The hospital process at the time was for the nursing staff to complete all discharge documentation with no clinician sign-off required. 

The nurse advised that she had printed the recent blood tests and attached them to Ms D’s discharge summary. She verbally confirmed with Ms D that she was aware of the need to follow-up with her GP. This conversation was not documented.

Dr R, the consultant in charge, had not been made aware of the abnormal results prior to Ms D’s discharge. He confirmed that had he been aware, he would also have advised GP follow-up and repeat blood tests within a few days.

How Medical Protection assisted

An inquest took place 18 months after Ms D’s death. Medical Protection’s legal advisers and counsel were instructed to assist our member, Dr B.

The legal team managed to avoid any direct criticism of the member at the inquest. Although Dr B’s instructions to Ms D had not been documented, her attendance at her GP practice provided evidence that the verbal instruction had been given and understood.

One year after the inquest, a letter of claim was received by Dr B. It was alleged that the failure to ensure that Ms D had a follow-up blood test within a week, or to ensure the GP was able to do so, was a breach of duty of care. It was also alleged that the failure to notify Dr R was a breach of duty. 

Medical Protection obtained an expert report to comment on the allegations of causation. This was supportive of our member and indicated that even if Ms D had been followed up sooner, it was unlikely that earlier treatment would have altered her outcome or prevented her death.

However, the risk remained that we would be unable to defend breach of duty due to the lack of documentation by any of the parties involved, and in particular by Dr B. The GP practice documented Ms D’s attendance to book herself in for blood tests. Had this not been done, Dr B would have no evidence that Ms D had been informed of her need to follow up.

Outcome

Following the inquest, the coroner concluded that the failure to ensure that a follow-up blood test did not cause or contribute to the death. He identified concerns with the discharge policy of the hospital. In particular, there was a lack of guidance on how post-discharge investigations should be arranged or communicated, by whom and when. The hospital took steps to ensure their discharge policy was rewritten, with clearer identification of roles and responsibilities.

As our member Dr B was not directly criticised, he avoided the need to self-refer to the Medical Council.

A letter of response was served to the claimant’s solicitors denying causation and the claim was withdrawn.

Learning points

This case highlighted the importance of ensuring that recommendations for follow-up are robustly documented in the notes and communicated effectively to the patient, along with expected timescales.

Clear and timely documentation to the GP would have indicated the reason for Ms D’s attendance and may have altered the timing of the appointment that was offered.

Had Ms D misunderstood the instructions in any way, there would have been no way of ensuring adequate follow-up was present.

Junior doctors working in rotation at various hospitals need to ensure they are familiar with local processes and clear on their responsibilities.

It is vital to ensure that supervising consultants are made aware of any problems with their patients prior to discharge. These conversations must always be documented. Consultants and juniors should establish expectations from each other on which matters should be escalated.

Although Dr R was not criticised in the claim, it is important for consultants to be satisfied that a clear follow-up plan is in place for their patients.

Ultimately, the overall responsibility for care does lie with the consultant in charge and therefore they must be content that appropriate care has been given. It is often difficult to document telephone conversations when covering multiple sites, but this must be done at the earliest opportunity.

As local discharge policies vary between hospitals, consultants must be aware of any nuances and be content that plans on discharge will be carried out. They should ensure that all letters are checked for accuracy as close to the point of discharge as possible.