From the case files: Working at scale

This case demonstrates some of the risks practices face when working at scale, and the importance of ensuring effective systems and communication across practices.

Mr F, a 45-year-old executive manager in a major sales company, saw his GP, Dr D, for a cold. Dr D noted from the records that Mr F had attended the Emergency Department ED three times prior to this for minor ailments. His blood pressure that day was 150/90mmHg and his BMI was 36.

He gave Mr F lifestyle advice and asked him to have his blood pressure checked. Mr F said he would not be able to take further time off during work hours for the BP check and Dr D’s practice did not offer extended opening hours. However, the practice was part of a federation, so it was agreed that Mr F would attend one of the other federation practices for this, as they offered healthcare assistant extended hours. Dr D also arranged for the patient to have a cholesterol test at the local phlebotomy clinic, which was nearer to the patient’s office.

Mr F did not attend the follow-up appointment for a blood pressure check. For some reason, Dr D was not informed of this by the other practice.

Six months later, Mr F attended his own practice again and was seen by a different doctor, Dr V. Looking at the notes, she saw that Mr F had attended evening and weekend appointments at other practices in the federation and received treatment for minor ailments six times since his last attendance at the practice. The result of his last blood test was not available but his cholesterol was significantly raised on the blood test taken six months ago. It appeared that no note had been sent to the patient to come in to discuss the result.

Once again, Mr F’s BP was raised, this time significantly higher than before, and Dr V was concerned. Dr V and Mr F discussed the best management option and Dr V decided to refer Mr F to cardiology based on this high reading, and started Mr F on an antihypertensive medication. She also offered a local patient education session on blood pressure, which Mr F declined. Mr F failed to attend the outpatient appointment.

Two months later, Mr F had an episode of indigestion. He again attended another practice in the federation for an evening appointment. When asked whether he was on any medication, Mr F said he was taking none. He was given antacids. However, he continued to have pain for three days on and off. He then suffered a cardiac arrest and unfortunately could not be resuscitated. The postmortem showed myocardial infarction.

A claim was made against all doctors involved, alleging that their failure to follow up and appropriately treat the risk factors for ischaemic heart disease, namely raised cholesterol and hypertension, had led to the patient sustaining a fatal cardiac arrest.

Expert opinion

Medical Protection instructed a GP expert to examine the case. The expert noted that there had been repeated blood pressures recorded in his notes from various appointments at multiple practices in the federation, and readings had been steadily increasing. He opined that the failure to instigate a proper management plan and the inadequate follow up constituted a clear breach of the GPs’ duty of care. The case was deemed indefensible and was settled for a substantial sum reflecting Mr F’s age and the fact he was a high earner and had dependent children. 

Learning points

• If GP federations share services, such as phlebotomy clinics and healthcare assistant (HCA) blood pressure checking, there should be clear communication between the services and processes in place to ensure that results are communicated and patients not lost to follow up.
• Arranging follow-up for any appointments missed or medication started makes practice safer. In this particular case, the patient missed an outpatient appointment and a HCA appointment and was not followed up for either non-attendance to find out what happened.
• When patients attend the ED multiple times for minor ailments, it may be worth addressing this in the consultation and explaining alternatives, such as the option to attend other practices within the federation, to avoid a lack of continuity of care.
• Any advice given to non-compliant patients should include the risks of failing to take medication or attend appointments, and should be documented.
• With poorly compliant patients, or those who are difficult to track, it is important to take advantage of opportunistic follow-up, and perform routine checks, such as blood pressure.
• Practices within federations should have robust policies in place regarding communication between healthcare providers and responsibilities for following up test results. The result should always be communicated back to the clinician requesting the test, and any DNAs should also be reported to the treating clinician.