Mrs B was a 27-year-old secretary with a ten-year-old daughter. She had just enjoyed a trip to Pakistan where she had been visiting relations. Three days after her return she developed profuse, watery diarrhoea. She made an appointment with her GP, Dr A, because she was opening her bowels seven times a day and couldn’t face eating anything.
Dr A noted that Mrs B had recently returned from Pakistan and that she had diarrhoea. Dr A was happy with Mrs B’s pulse and blood pressure and documented her temperature as 37 degrees. Dr A found Mrs B’s abdomen to be soft and non-tender. Dr A prescribed some paracetamol and co-phenotrope and advised her to return if there was no improvement.
Mrs B waited for a week but she began to feel worse – she was so nauseous that she still couldn’t eat and the diarrhoea had been relentless for ten days. Mrs B was feeling rather weak so she made another appointment with Dr A. Dr A’s notes were brief, just stating “diarrhoea”. Dr A noted that Mrs B was apyrexial with a satisfactory pulse and blood pressure. Dr A examined Mrs B’s abdomen again and found it to be soft, he prescribed some codeine linctus and loperamide.
Two days later Mrs B began to feel very faint and lethargic with ongoing diarrhoea. She had been staying with her mother-in-law who was really worried about her. Her mother-inlaw drove Mrs B’s daughter to school, then took Mrs B to her GP surgery where she was given an emergency appointment. Dr A saw her again and found her restless and sweating with a tender abdomen, this was recorded in the notes. He admitted her to hospital with possible enteritis or malaria.
Mrs B was investigated in hospital with thick and thin films, blood cultures, and a stool culture. Mrs B was commenced on empirical oral ciprofloxacin and intravenous fluids. An M early report from the microbiologists stated that her blood cultures had grown a gram negative rod, likely to be salmonella and that ciprofloxacin was the appropriate therapy. After two days of treatment Mrs B refused to take any more tablets because her nausea was so severe and she was commenced on intravenous ciprofloxacin.
The following day Mrs B had a cardiac arrest and despite adrenaline and DC cardioversion she died. A postmortem report showed she had died of a gram negative septicaemia and gastroenteritis with salmonella paratyphi A.
Mrs B’s family were devastated and made a claim against Dr A. They felt that her death could have been avoided if Dr A had investigated and treated her diarrhoea earlier.
Expert Opinion
Medical Protection commissioned a report from a GP expert, Dr S. Dr S was not critical of Dr A’s first consultation with Mrs B. At that time Mrs B had a three-day history of diarrhoea. Dr S explained that viral gastroenteritis is the commonest cause of diarrhoea and that traveller’s diarrhoea is an extremely common presenting complaint.
Even in cases of bacterial infection, antibiotic treatment is not usually required. As traveller’s diarrhoea is self-limiting in the majority of cases, Dr S felt that few GPs would have requested a stool sample on that occasion.
Dr S was, however, critical of Dr A’s second consultation. At that time Mrs B had complained of significant diarrhoea for ten days. Dr S felt the clinical records were very brief and did not include a record of the presence or absence of blood in the stool or abdominal pain.
Dr S thought that the patient’s ongoing symptoms at this consultation required the identification of a causative organism and that a stool culture should have been arranged. It was his view that the failure to do so represented an unreasonable standard of care. He postulated that if a stool sample had been taken, this would have led to the causative organism being known within four to seven days.
The case was settled for a moderate sum.
Learning points
- Poor record keeping is a major factor in litigation cases brought against healthcare professionals. Good medical records are not only essential for continuity of patient care, they are also vital for defending you if you face a complaint or clinical negligence claim.
- Doctors should take and document a detailed history to help differentiate between benign and more serious conditions. Common symptoms can occasionally point to serious pathology.
- It is important to reassess patients carefully if they are not improving.
- GPs see a lot of patients with diarrhoea. It is worth remembered what on the face of it could be a benign condition, can catch you out if you don’t take a proper history and look at the whole patient. Common conditions usually follow the expected course, but you must be alive to those that don’t behave as expected.