A patient attended his GP complaining of rectal bleeding, which he'd been experiencing on and off for the past year. An examination and proctoscopy didn't reveal any abnormality, and the GP asked standard questions, including whether there had been any change in bowel habit. The patient said he'd not experienced any change, but the GP didn't record this in the notes because she would generally only record positive findings.
As there was no obvious cause for the intermittent bleeding and the patient didn't meet the NICE criteria for urgent referral for an appointment within two weeks, the GP made a routine referral for surgical review and the claimant was seen around five weeks later.
The claimant was subsequently diagnosed with colorectal carcinoma and made a claim against the GP for failing to refer him urgently, leading to a four week delay in diagnosis. The GP contacted the MDU for advice and support.
The letter of claim alleged that if the patient had been referred under the two week rule, the tumour would have been smaller when diagnosed and the patient would have avoided four weeks of pain, suffering and anxiety.
The claim was therefore of low value, but the MDU nevertheless sought an independent GP expert's opinion, which supported the GP's management.
The records from the subsequent referral also helped, as they revealed a normal haemoglobin level and that the patient had told another clinician that his bowel habit hadn't changed, thus supporting the GP's factual account.
The MDU responded to the letter of claim denying breach of duty and stating that even if the GP had been in breach, which was not accepted, the records didn't reveal any evidence of the patient having suffered pain or anxiety during the alleged delay in diagnosis. Liability was denied and the case against the MDU member was discontinued.
Despite the outcome, this case shows that recording negative findings as well as positive ones in a patient's notes can be helpful in providing an accurate record of events. Clinical records are very often a vital component in allegations of negligence, and completeness can be key.
Case studies are published for educational purposes, and allow MDU members to share their experiences of facing complaints and claims so that others can apply the lessons learned to their own practice.
The cases are based on real events and have been published with permission, but some details have been changed to preserve the anonymity of those involved.
If you think your colleagues would benefit from reading about your experiences and you'd like to share them in the journal, please contact firstname.lastname@example.org