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Follow-up of referral; appropriate examinations (14HDC00919)

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(14HDC00919, 15 August 2016)

General practitioner ~ Medical centre ~ Public hospital ~ District health board ~ Referral ~ Respiratory failure ~ Coronary artery disease ~ Examinations ~ Communication ~ Follow up ~ Rights 4(1), 4(2)

A 38-year-old man began to have coughing fits, particularly at night. He saw his GP, who thought the man might have an infection in his chest, and prescribed antibiotics.

A few months later the man returned to his GP because of further coughing fits, bleeding from the nose, and episodes of shortness of breath. The GP documented that a specialist assessment was required. The GP sent a semi-urgent referral to the District Health Board's (DHB) respiratory service. The referral gave no indication of the duration and severity of the man's symptoms or the duration of his smoking history, and no physical findings were included other than blood pressure.

One night, the man experienced continual coughing for about eight hours. He returned to his GP the following day and told him what had happened. The GP ordered a full set of blood tests and documented that the man needed an urgent respiratory appointment. The GP told HDC that at this point he sent off a referral to the DHB for urgent specialist assistance, but there is no evidence of that referral in the medical notes, and the DHB did not receive it.

The man returned to the GP a week later. Following that appointment, the GP sent a new referral to the DHB, this time for specialist gastroenterology review. The DHB informed the GP that an appointment had been booked for the man at "the medical clinic". The GP assumed this appointment was for the specialist respiratory appointment. In fact, it was for the gastroenterology review. The DHB subsequently informed the man that he had also been booked in for respiratory testing on a different date. However, the DHB did not inform the GP about the respiratory testing.

The man visited his GP again a week after his previous appointment, but as the GP was already fully booked with other patients, he did not review the man formally or examine him physically. However, he did see him and prescribed an antibiotic.

Sadly, the man died the following day. His post-mortem recorded his cause of death as "respiratory failure due to severe pulmonary oedema and pleural effusions". He was found to have had severe coronary artery disease, signs of an old myocardial infarction (a heart attack), and an enlarged liver.

It was held that the GP failed to advocate appropriately for the man by failing to follow up the respiratory referral or inform the DHB when the man's condition deteriorated, and failed to carry out the appropriate physical assessments of the man before prescribing an antibiotic. Accordingly, the GP failed to provide services with reasonable care and skill and breached Right 4(1). There was also found to be a pattern of inadequate documentation in the GP's referral letter and clinical notes. Accordingly, the GP breached Right 4(2).

Adverse comment was made about the DHB regarding its communication with the GP.

It was recommended that the GP undertake further education and training on clinical documentation, and report back to HDC on the effectiveness of changes he had made to his practice following the events in question. It was also recommended that the DHB report back to HDC regarding changes made to its communication system.

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