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Follow-up of blood test results (14HDC00894)

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(14HDC00894, 18 February 2016)

General practitioner ~ Medical centre ~ Clinical trial ~ Blood test results ~ Anaemia ~ Right 4(1)

A man was enrolled in an ongoing clinical trial. Regular blood tests were taken as part of the trial, and the trial clinicians undertook to notify participants' general practitioners (GP) of any significantly abnormal findings.

The man consulted his GP and had routine screening blood tests, which showed a slightly low haemoglobin level. About a year later, blood tests were ordered as part of the trial which showed a low haemoglobin level. A trial clinician sent the man's GP a letter with a copy of the man's blood results. Neither the letter nor the results are in the clinical record. The man took a copy of the letter to a subsequent appointment with the GP, and the GP recorded that the man had mild anaemia. The GP prescribed the man iron supplements.

The first of two further blood test results ordered six months later by the trial clinicians showed that the man had a low haemoglobin level; the second test showed he had a haemoglobin level within the normal range. The GP told HDC that the first set of results did not confirm iron deficiency, and that he did not receive the second set of results.

The GP ordered further blood tests approximately eight months later which showed a haemoglobin level below the normal range and low ferritin. The GP informed the man that he was mildly anaemic and prescribed further iron supplements.

The man transferred to another GP fourteen months later (having not seen a GP during that period), who referred him for blood tests which revealed a significantly low haemoglobin level. Nine weeks later, the GP asked the man to return for a follow-up appointment and then referred him for a colonography and a gastroscopy which revealed a malignant tumour in the man's stomach. While awaiting a laparoscopy, the man developed neurocognitive symptoms and brain metastases and later died.

It was held that by not determining the possible underlying cause of the man's anaemia, failing to organise structured follow-up, and not discussing the blood test results with the man, the first GP failed to provide services to the man with reasonable care and skill and breached Right 4(1).

Adverse comment was made about the first GP in relation to his documentation and management of test results, and about the lack of such policy at his GP practice.

It was held that because the second GP did not follow up on the man's abnormal haemoglobin level for nine weeks, he failed to provide services to the man with reasonable care and skill and breached Right 4(1).

Adverse comment was made about the lack of a policy for the management of test results at the second GP's practice. 

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