A hidden problem

Mr T, a 40-year-old accountant, attended a private health check under his employer’s healthcare scheme. Blood and protein were noted on urinalysis and his eGFR was found to be 45 ml/min/1.73 m2. He was asked to make an appointment with his GP and was given a letter highlighting the abnormal results to take with him.

Mr T saw his GP, Dr W, shortly after and told her that blood had been found in his urine on dip testing during a health check. Dr W arranged for an MSU to be sent to the laboratory. The MSU showed no infection or raised white cells but did confirm the presence of red blood cells. Unfortunately the result was marked as “normal” and filed in the notes without any action.

One year later Mr T saw Dr W again with a painful neck following a road-traffic accident. Dr W prescribed diclofenac tablets to help with the discomfort. One week later he booked an urgent appointment because he had developed a severe headache and felt very lethargic and breathless. He was seen by Dr A, who diagnosed a chest infection and prescribed a course of amoxicillin.

Mr T went home but was taken to hospital later the same day following a fit. He was subsequently diagnosed with malignant hypertension and severe renal failure with pulmonary oedema. Again, blood and protein were found in his urine but this time his eGFR was 12 ml/min/1.73 m2. Mr T stabilised but needed assessment for possible kidney transplantation.

Mr T was angry and upset about the care he had received from his GP. He alleged that he had given Dr W a letter from the healthcare assessment when he consulted with her and that she had failed to act on it. He also alleged that Dr W had failed to diagnose his renal disease or refer him to the renal team. He claimed that this delay had resulted in progression of his condition to end stage renal failure.

Expert opinion

Medical Protection sought the advice of a consultant nephrologist, Dr B. Dr B was of the opinion that Mr T’s renal impairment was probably due to glomerusclerotic disease rather than hypertension at the time of the health check. He felt that the diclofenac prescribed caused the clinical situation to deteriorate, leading to the acute presentation of severe hypertension and renal failure. He advised that if Mr T’s condition had been diagnosed earlier, this would have allowed monitoring and control of his blood pressure. It would also have been unlikely that NSAIDs would have been prescribed, thus avoiding the acute presentation. It was Dr B’s opinion that earlier diagnosis and treatment would have delayed the need for renal transplant by a period of between two to four years.

Dr W specifically denied that she had been given the letter from the private health check and indeed there was no evidence of it within the GP records. She did, however, accept that she had erroneously marked the MSU result as normal and had thus not taken any action. In view of this, it was agreed that Dr W was in breach of duty in this matter and the case was settled for a high sum.

Learning points

• This case raises issues about communication between healthcare providers. The GMC states that “you must contribute to the safe transfer of patients between healthcare providers and between health and social care providers”. Doctors need to consider whether their 1 systems for receiving and recording information, written or verbal, from other healthcare providers are sufficiently robust.
• Mistakes can be easily made when working under stress with high workloads. It is important, however, to be thorough and to ensure that all elements of a test result are reviewed before marking the result as ‘normal’.
• The assessment and management of non-visible haematuria in primary care is discussed in a useful clinical review published by The BMJ in 2009..2

References

1. GMC, Good Medical Practice, paragraphs 44 and 45, ‘Continuity and Coordination of care’.  
2. Kelly JD, Fawcett DP and Goldberg LC, Assessment and Management of Non-visible Haematuria in Primary Care, BMJ 338: a3021(2009)