From the case files
Post date: 04/06/2013 | Time to read article: 5 minsThe information within this article was correct at the time of publishing. Last updated 18/05/2020
The GMC’s latest Good Medical Practice reflects the ever-changing demands of modern healthcare provision, says Dr Rachel Birch, and these two cases illustrate two areas where the GMC has expanded its guidance
Mrs A, 48-years-old, consulted with Dr H on the last Friday in the job. She told him that she had irritable bowel syndrome, which had been diagnosed several years ago, and that it was worse at times of stress.
She admitted to being under a lot of pressure recently as she was juggling work, a postgraduate course and three teenage children. She was experiencing generalised abdominal pain and a feeling of being full after even the smallest meal. She felt tired and she was putting on weight. Her abdomen felt bloated all the time.
On examination she had generalised abdominal tenderness, but no masses. Dr H did not perform a pelvic examination, but asked her to return for a blood test the following week. He told her that she probably had an exacerbation of her irritable bowel syndrome, but that she would need a blood test to rule out anything more serious. He said she should see one of the other doctors for the results.
Mrs A attended for the Ca125 blood test. She wasn’t contacted by the practice staff regarding the result and assumed everything was therefore normal. Despite the fact that her pain persisted and the bloating worsened, she felt there was no point going to see any of the other doctors as it was her irritable bowel “playing up”.
Three and a half months later Mrs A came to see Dr R, one of the partners at the practice. She was feeling really tired, noticing increasing swelling of her abdomen and worsening pain and starting to experience frequency of urination.
"On reviewing the medical record it became clear that although the Ca125 blood test had been carried out, the result had never been received at the practice"
Dr R examined her abdomen and found that she had significant ascites. A pelvic examination revealed a tender mass in the right adnexa. On reviewing the medical record it became clear that although the Ca125 blood test had been carried out, the result had never been received at the practice.
Dr R telephoned the laboratory and was told that the patient’s Ca125 was significantly raised. Mrs A was referred urgently to Gynaecology and underwent a staging laparotomy, where she was found to have advanced ovarian cancer. She underwent a total abdominal hysterectomy and bilateral oophorectomy and started chemotherapy within a few weeks
Despite the treatment her prognosis remained poor. Mrs A made a claim against Dr H and the practice.
Expert opinion
Expert opinion was that although Dr H considered the possible diagnosis of ovarian cancer, he could be criticised for not explaining his concerns to the patient and not ensuring that the patient had appropriate follow up.
The practice was criticised for not having a robust method for tracking test results to ensure that they are received by the practice and seen by a doctor. It was felt that these shortcomings led to a late diagnosis of ovarian cancer – had the cancer been diagnosed earlier the patient would have had a chance of a better outcome and prognosis. The claim was settled for a modest sum.
What the GMC says
- Doctors must contribute to the safe transfer of patients between healthcare providers
- Doctors must share all relevant information with colleagues involved in their patient’s care. They must pass on relevant information about the patient’s condition and history
- Doctors must make sure the patient is informed about who is responsible for their overall care
- Patients should be advised who to contact if they have questions or concerns about their care.
Learning points
- As he was concerned about the possibility of ovarian cancer, Dr H should have shared this concern with the patient and explained the purpose of the blood test
- He should have booked the patient a follow-up appointment with a GP colleague
- Dr H should have discussed Mrs A’s presentation with a GP colleague, so that the GP could ensure he looked out for the test result and reviewed the patient.
The perils of peer group forums
Dr M quickly found that she enjoyed sharing difficult dilemmas and case reviews with her peers. Every few days she would post clinical scenarios and obtain other trainees’ feedback on the various issues. She learnt a lot from reading about other trainees’ experiences too. One of the cases she posted was regarding a 55-year-old male patient, Mr X, who had had a cerebrovascular accident. This had left him with profound weakness down one side of his body, but he managed to mobilise and retain his independence by the use of a walking frame. He came to see Dr M with low mood and anxiety. He was having difficulty having a satisfactory sexual relationship with his partner, which was the main cause of his mental health symptoms. Dr M received some useful advice and support from her peers, but unfortunately one of the trainees posted a rather unhelpful and derogatory remark about the patient. Whilst Dr M did not agree with the comment, she was unable to remove it from the thread. Since the forum was anonymous, she didn’t know which of the other trainees had made the remark. "Whilst Dr M did not agree with the comment, she was unable to remove it from the thread" The following day Mr X came to see the senior partner. He was very angry and distressed. He had been on the GP trainees’ online forum and had read the thread regarding his consultation. Whilst the details were anonymous, and the GP’s name wasn’t posted, he was able to recognise himself from the description of his unilateral weakness and walking frame. He discussed the matter with the senior partner and proceeded to write a formal complaint to the practice about Dr M. Mr X was unhappy that Dr M had given a description, such that he was able to identify himself. He did not appreciate the derogatory comments, and the fact that Dr M had made no attempt to disagree with the post. He felt that the security and privacy settings were poor and that anyone could potentially go into this so-called private forum and review the comments. Mr X’s complaint was shared with the GP trainee and she and the senior partner proceeded to meet with him. Dr M offered an apology for the breach of confidentiality and also expressed regret that unhelpful comments had been posted on the forum. She agreed to share the complaint with the GP trainee group as a significant event analysis and promised to feed back the outcome to Mr X in due course. What the GMC says
What should the practice do?
Useful links
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Dr M was an ST3 GP trainee in a busy practice in a market town. She took part in regular deanery training sessions, and her educational supervisor had suggested that she join an anonymous online forum that had been set up by one of the local GP training groups.
