Fifteen years of urinary tract infections – what’s the cause?

Mrs Q had undergone a kidney transplant and, after surgery, re-presented with urinary tract infections on a number of occasions over a 15-year period. It was later found that Mrs Q had a retained ureteric stent from her transplant, and she brought a claim against Dr X, the genitourinary consultant who provided follow-up care.

Dr X contacted Medical Protection and requested assistance. When discussing the case with our medicolegal consultant, he explained that imaging of Mrs Q’s urinary system was not clinically indicated during the periods of urinary symptoms because there was no indication of a structural or obstructive abnormality to warrant imaging studies. He also said Mrs Q was predisposed to urinary tract symptoms and infections because of her history of kidney transplant and chronic immunosuppression, her gender, age, and the menopause.

Expert opinion

The expert instructed by Medical Protection was supportive of Dr X’s approach, including his decision to prescribe prophylactic antibiotics instead of ordering an ultrasound scan during the second cluster of urinary symptoms.

In addition, the expert also highlighted that Mrs Q failed to attend various follow-up consultations and was often non-compliant with the medical therapy for her chronic kidney disease, hyperlipidemia, gout and arthritis, which may have contributed to the symptoms she complained of. In particular, Mrs Q’s non-compliance with allopurinol treatment may have caused more frequent flares of her gouty arthritis, and failure to follow up with gynaecology caused persistence of her vaginal symptoms.

Medical Protection successfully defended the claim and it was discontinued by Mrs Q.

Learning points

• The experts we instruct will examine a case carefully to understand and reconstruct the information that was reasonably available to the treating doctor at the relevant time. For example, in this case, there was no reason for Dr X to suspect a retained ureteric stent, as the operating surgeon had made no record of stent insertion.
• Experts also analyse and comment on the impact of a patient’s non-compliance with treatment and non-attendance at follow-up appointments, and provide an opinion on the consequences for the patient’s clinical course and symptoms.