A 43-year old patient reported calf pain which was diagnosed as a sports injury by her GP, an MDU member. At the same time she was referred for a chest x-ray for her ongoing cough. The x-ray showed a shadow which needed further investigation and the patient was referred for a CT scan. The CT appointment was arranged for a date two months after her initial complaint of calf pain.
In the interim, over a bank holiday weekend, the patient experienced an episode of chest pain and haemoptysis. This had settled but she rang her GP a week afterwards to tell him about it. She reported continuing mild shortness of breath on exertion.
The GP was reassured by the fact that the patient had not sought medical attention for a week before contacting him and that her symptoms had largely resolved by the time of the telephone consultation. Being concerned about a possible diagnosis of lung cancer, as a cause for her reported shortness of breath on exertion, the doctor expedited the patient’s CT scan under the two-week rule.
“It was alleged that the claimant should have been referred to A&E immediately.”
The CT scan took place 13 days later and showed a massive bilateral pulmonary embolism involving both pulmonary arteries. The discharge summary referred to chest pain and calf swelling over the previous three months.
The claimant subsequently instructed solicitors who alleged that the GP had been negligent in failing to consider and rule out a pulmonary embolism. It was alleged that the claimant should have been referred to A&E immediately.
The MDU obtained independent expert evidence from a GP who advised that a combination of haemoptysis and shortness of breath, with a recent episode of chest pain lasting several days – as reported by the claimant during the telephone consultation – merited at least an urgent, detailed GP assessment. The MDU’s haematology expert advised that at the time of that telephone consultation the claimant would probably not have had elevated jugular venous pressure, a gallop rhythm or systemic hypotension, as such signs would have made her feel sufficiently unwell to seek emergency help rather than telephone her GP. However, he believed the claimant would have reported ongoing chest pain if asked in more detail. He could not be certain as to whether the claimant would have had tachycardia, tachypnoea, pyrexia or a pleural rub, as all those symptoms could have been transient. Similarly, the haematologist was unsure what the claimant’s Well’s score for pulmonary embolism would have been on the day of the phone call.
The GP accepted that his notes of the consultation were brief and that he should have asked the claimant further questions, either on the telephone or during a face-to-face consultation, to rule out a differential diagnosis. He also accepted the MDU’s advice that there was a significant litigation risk that a judge trying the case would be likely to find that the claimant would have reported ongoing chest pain and calf swelling had she been assessed in more detail. This would have led to a referral to A&E where an elevated d-dimer would have been measured which, together with additional investigations, would have led to an immediate clinical diagnosis of pulmonary embolism.
The claimant accepted £1,500 for the pain and suffering she experienced as a result of the 13-day delay in diagnosis. The claimant’s solicitors accepted that the claimant would have had the same management and medical outcome, including the need for indefinite anticoagulation, had she been diagnosed 13 days earlier.
Senior claims handler
The member involved in this case comments:
The old adage "assume nothing" is really important - I should have listened to the new symptoms and re-formulated my differential diagnosis and brought the patient in for review. Following clinical review (it is likely the examination would have remained normal) I may have adopted the same approach with a working diagnosis of lung mass but the failure to call the patient in for examination was key here and led to the lawsuit.
From a personal perspective, it was not nice to have litigation directed against me but I tried to approach it as a learning experience. The MDU were there to support me throughout the process and were fantastic.
I've certainly learnt from this episode and it has changed my practice. I now have a much higher index of suspicion for PE, which has lead to identifying a number of PEs I may not have previously diagnosed in a timely fashion.