Minimise risk of medical lawsuits
GPs need to be more aware than ever of the risk of missing or delaying a diagnosis, says Dr Mayur Lakhani
Scenario 1 Systems failure may be sight-threatening
A practice received a letter from an optometrist recommending referral of a patient with raised intra-ocular pressure and suspected glaucoma. The GP expected the patient to attend for this to be organised but the patient understood she would be referred directly by the GP. No referral was made and several months later the patient contacted the practice. There was also a significant waiting list to be seen which compounded the delay. Current medical opinion would find the GP at fault for not acting on a recommendation by the optometrist for referral.
Issue: Potential delay in diagnosis of sight-threatening disease because of a systems failure in dealing with correspondence and tracking patients
Scenario 2 Delayed diagnosis of rare paediatric tumour
A pre-school child had been referred to hospital for investigation of lethargy and non-specific illness. The child had had several medical admissions and outpatient attendances. Subsequently representations were made to the GP that 'something more be done'. The practice believed the child was under hospital investigation and, therefore, there was nothing more to be done. The GP wrote a letter seeking clarification of the management plan. In the interim the child deteriorated and was admitted by the GP. Subsequent investigation showed a rare neoplasm.
Issue: Even though a patient may be under hospital investigation with initial negative investigations, the GP should keep an open mind and consider alternative diagnosis
The MDU advice
Helen Goodwin, clinical risk manager at the MDU, advises that if you face litigation for missed diagnosis it is possible to mount a successful defence provided the clinical management can be shown to be competent and reasonable, as judged by a responsible body of peers (the Bolam test3).
A recent review by the MDU of its settled missed diagnosis cases identified the following problems:
lfailure to examine the patient properly
linadequate follow-up arrangements
llack of appropriate investigations
lpoor communication with colleagues and patients
lmisfiling reports (usually paper copies)
lincomplete or inadequate records (either lack of notes or a failure to record an appropriate management plan).
To minimise the risk of delayed diagnosis, the MDU suggests you:
lExplain the likely response time for treatment to take effect, and follow up plans to patients and note these in the patients' records.
lMake a full record of all consultations, including telephone. Record relevant negative findings.
lInclude a management plan, formulated from an appropriate history and examination.
lEnsure referral letters are written promptly and include details of:
•Results of investigations
•Relevant social factors
•Degree of urgency
•What you expect from the referral.
lHave a system in place that allows for prompt transfer of out-of-hours consultations to the patients' records. Make sure patients seen out-of-hours are reviewed for follow-up if necessary.
lEnsure all staff are aware of protocols for covering urgent requests for visits.
lMaintain a thorough system to record all laboratory samples and tests requested. Ideally, this should include a mechanism to check receipt of all results.
lReview and sign all test results.
lEnsure there is a clear system for results to be checked when partners are on leave or locums are working in the practice.
lRecord the decision to see a patient with the results of a test, and recall the patient if this is urgent.
lEnsure any recall systems include an alert notification if patients fail to respond.
References and websites
1 The frequency and nature of medical error in primary care: understanding the diversity across studies. John Sandars and Aneez Esmail. Family Practice 2003; 20(3): 231-6
3 Bolam v Friern hospital management committee (1957) 1 Weekly Law Report, 582
Mayur Lakhani and Helen Goodwin are speaking at a conference on missed and delayed diagnosis in general practice in London on Thursday June 10