Diagnosis pneumonia out of hours

Mr B was a 31-year-old man with three children. His mother was staying with him over the weekend because he was in bed coughing and shivering. On Saturday he complained of chest pains so his mother rang an ambulance. The paramedic recorded a temperature of 39 degrees, oxygen saturations of 94%, pulse 134, respiratory rate of 16 and a blood pressure of 120/75. An ECG was done and noted to be normal. The paramedic explained to Mr B that he should be taken to hospital. Mr B declined and was considered to have capacity so the ambulance left.

The ambulance crew called their control centre who in turn contacted an out-ofhours GP, Dr Z. The control centre left a verbal message for Dr Z, explaining the situation, but did not hand over details of Mr B’s vital signs including his oxygen saturations and pulse rate.

Dr Z rang Mr B and noted his history of chest pain triggered by coughing and the normal ECG. She noted his temperature of 39 degrees and that he had taken some ibuprofen to help. She documented “no shortness of breath” and advised some cough linctus and paracetamol. She offered M him an appointment at the out-of-hours centre, which he declined, but he did agree to ring back if he was worse. She documented that her advice had been accepted and understood.

Mr B was no better on Sunday so his mother rang the out-of-hours centre again. This time a nurse spoke to Mr B and noted his history of productive cough, fever and aching chest pain. She documented that he had some difficulty in breathing on exertion but that he could speak in sentences over the telephone. Again she offered him an appointment at the out-of-hours centre but he refused, saying he would prefer to see his own GP on Monday.

Three days later Dr B’s mother took him to see his own GP. He found coarse crepitations in his right upper and mid chest but with good air entry. He noted that Mr B was not unduly distressed and had no shortness of breath so opted for oral antibiotics and a review in two days.

Later the same day Mr B’s breathing became rasping and very laboured. He collapsed and an ambulance took him to A+E. Cardiopulmonary resuscitation was attempted but sadly failed. A post mortem was performed, giving the cause of death as “right-sided lobar pneumonia and bilateral pleural effusions”.

Mr B’s mother was distraught and brought a claim against the out-of-hours GP, Dr Z. She claimed that her son had been extremely short of breath on the telephone and that she had not paid adequate attention to this. She was upset that Dr Z had not arranged to visit her son at home and had incorrectly diagnosed a simple chest infection.

Expert opinion

Medical Protection obtained expert opinions from a GP and a respiratory specialist. The GP was supportive of Dr Z. He noted that cough, fever and malaise are very common symptoms in a young adult. He listened to the recorded consultation and considered Mr B to have been only mildly short of breath and showing no verbal signs of delirium. He felt it was reasonable for Dr Z to suggest attendance at the primary care centre. He also noted that if Mr B had been well enough to attend his own GP four days later, then he could probably have travelled to see Dr Z on the day she spoke to him. He felt it had been neither possible nor necessary to define the diagnosis beyond a respiratory tract infection during their telephone consultation. He thought it was unhelpful that Dr Z had not received Mr B’s oxygen saturations or pulse rate from the ambulance crew.

The respiratory specialist noted that Mr B was assessed by the ambulance crew on the same day he consulted with Dr Z on the telephone. At that time he was not confused, his respiratory rate was 16 and his blood pressure was satisfactory. This would have given him a CRB65 score of 0, which is associated with a good prognosis. He commented that this, along with clinical judgement, would have supported homebased care for this patient rather than the need for hospital assessment.

It was highlighted that Mr B had refused to go to hospital with the ambulance crew and to attend the out-of-hours centre. This and the supportive expert opinion helped Medical Protection to successfully defend Dr Z.

Learning points

• Medical Protection can use recorded data as evidence to support members who are the subject of a claim. GPs working out-of-hours should be aware that a telephone recording is an additional record of the consultation when speaking to patients on the telephone.  
• According to NICE guidance, after diagnosing pneumonia GPs should use the CRB65 score to determine the level of risk and help guide decisions on where to manage a patient1. One point is given for confusion (AMTS 8 or less or new disorientation in person, place or time), raised respiratory rate (30 breaths per minute or more), low blood pressure (systolic <90mmHg or diastolic <60mmHg), age 65 years or more. A score of 0 is classed as low risk and is associated with less than 1% mortality. A score of 1 or 2 is classed as intermediate risk and is associated with 1-10% mortality. A score of 3 or 4 is classed as high risk and is associated with more than 10% mortality.
• When communicating between healthcare services, it is important to hand over all relevant information. In this case the ambulance crew did not pass on the patient’s low oxygen saturations or his raised pulse rate. These vital signs could have conveyed the severity of the patient’s illness to the out-of-hours GP