Tunnel vision
Post date: 26/10/2017 | Time to read article: 2 minsThe information within this article was correct at the time of publishing. Last updated 18/03/2019
Mrs O, a 34-year-old mother of three, visited her GP with a two-month history of worsening vaginal discharge which had become malodorous recently. Her husband had urged her to see the doctor because he was particularly concerned when she had admitted to the discharge being blood stained.
The first GP she saw, Dr A, took a cursory history and simply suggested she should make an appointment with the local GUM clinic. Of note, Dr A didn’t enquire about the nature of the discharge, associated symptoms or note that she had not attended for a smear for over five years, despite invitations to do so. Dr A did not examine Mrs O, nor did he arrange investigations or appropriate follow-up. Mrs O was deeply offended that Dr A had implied the discharge was likely to be secondary to a sexually transmitted infection and did not feel the need to attend a GUM clinic.
She re-presented to another GP, Dr B, several months later, complaining that her discharge had worsened. Dr B reviewed the previous notes and encouraged her to make an appointment with the GUM clinic as recommended previously by Dr A. There was no evidence from the notes that a fresh review of the history had been undertaken. No examination was performed and Dr B did not arrange vaginal swabs or scans despite Mrs O’s continued discharge.
One week later, Mrs O re-attended the surgery where Dr B agreed to try empirical clotrimazole on the premise she may be suffering from thrush. Again, no examination or investigations were discussed, and there was no evidence of safety netting advice documented in the records.
Two months later, Mrs O saw a third GP, Dr C, because the clotrimazole had failed to resolve her worsening symptoms. By now she had started to lose weight, had developed urinary symptoms, and her bloody vaginal discharge had worsened. Despite her malaise and pallor, Dr C again failed to take an adequate history or examine Mrs O and further reinforced the original advice that Mrs O attend the GUM clinic.
Mrs O collapsed later that week and was taken by ambulance to the A&E department of her local hospital. She was found to have urosepsis and was profoundly anaemic with a haemoglobin of 60 g/l. Examination by the A&E team revealed a hard, irregular malignantlooking cervix and a large pelvic mass. She was admitted under the gynaecology team, who arranged an urgent scan. The scan revealed an advanced cervical cancer with significant pelvic spread and bulky lymphadenopathy.
After an MDT meeting and a long discussion with her oncologist, Mrs O and her husband elected to try a course of neoadjuvant chemotherapy and debulking surgery. Unfortunately, prior to surgery, she experienced severe pleuritic chest pain and a working diagnosis of pulmonary embolism was made. Further investigations excluded embolic disease but confirmed tumour deposits in the lung and liver.
It was agreed she would forego chemotherapy and Mrs O was referred to the palliative care team. Her symptoms were managed in the community until her death at home two months later.
The first GP she saw, Dr A, took a cursory history and simply suggested she should make an appointment with the local GUM clinic. Of note, Dr A didn’t enquire about the nature of the discharge, associated symptoms or note that she had not attended for a smear for over five years, despite invitations to do so. Dr A did not examine Mrs O, nor did he arrange investigations or appropriate follow-up. Mrs O was deeply offended that Dr A had implied the discharge was likely to be secondary to a sexually transmitted infection and did not feel the need to attend a GUM clinic.
She re-presented to another GP, Dr B, several months later, complaining that her discharge had worsened. Dr B reviewed the previous notes and encouraged her to make an appointment with the GUM clinic as recommended previously by Dr A. There was no evidence from the notes that a fresh review of the history had been undertaken. No examination was performed and Dr B did not arrange vaginal swabs or scans despite Mrs O’s continued discharge.
One week later, Mrs O re-attended the surgery where Dr B agreed to try empirical clotrimazole on the premise she may be suffering from thrush. Again, no examination or investigations were discussed, and there was no evidence of safety netting advice documented in the records.
Two months later, Mrs O saw a third GP, Dr C, because the clotrimazole had failed to resolve her worsening symptoms. By now she had started to lose weight, had developed urinary symptoms, and her bloody vaginal discharge had worsened. Despite her malaise and pallor, Dr C again failed to take an adequate history or examine Mrs O and further reinforced the original advice that Mrs O attend the GUM clinic.
Mrs O collapsed later that week and was taken by ambulance to the A&E department of her local hospital. She was found to have urosepsis and was profoundly anaemic with a haemoglobin of 60 g/l. Examination by the A&E team revealed a hard, irregular malignantlooking cervix and a large pelvic mass. She was admitted under the gynaecology team, who arranged an urgent scan. The scan revealed an advanced cervical cancer with significant pelvic spread and bulky lymphadenopathy.
After an MDT meeting and a long discussion with her oncologist, Mrs O and her husband elected to try a course of neoadjuvant chemotherapy and debulking surgery. Unfortunately, prior to surgery, she experienced severe pleuritic chest pain and a working diagnosis of pulmonary embolism was made. Further investigations excluded embolic disease but confirmed tumour deposits in the lung and liver.
It was agreed she would forego chemotherapy and Mrs O was referred to the palliative care team. Her symptoms were managed in the community until her death at home two months later.
Expert opinion
A claim was brought against all three GPs for failure to take adequate histories, failure to examine, failure to accurately diagnose and failure to safety net. An expert witness was highly critical of the care Mrs O received from all the GPs involved and advised that her death was potentially avoidable with better care and a more robust system for smear recall. Breach of duty and causation were admitted and the family’s claim was settled for a high amount.
Learning points
- Failure to take an adequate history and examination will make any case difficult to defend.
- It is not advisable to reinforce a colleague’s diagnosis or management advice without first conducting your own assessment of the patient’s symptoms.
- Alarm bells should ring if patients return multiple times for the same problem.
- Where clinically relevant, a screening test should be offered opportunistically to patients who fail to respond to routine invitations.
