Names have been removed to protect privacy. Identifying letters are assigned in alphabetical order and bear no relationship to the person's actual name.
The Commissioner received a complaint from the consumer about the care he received from the general practitioner at the medical centre. The complaint is that:
- On the morning of a day in early February 1998, the consumer had acute stomach pains and a high temperature. The consumer went to the medical centre where he saw the GP. The GP informed the consumer that he had constipation and sent him home with 36 microlax enemas. The GP did not diagnose the consumer's appendicitis.
- The consumer returned to the the medical centre the following day. He had similar symptoms and was again attended to by the GP, who again did not diagnose the consumer's appendicitis.
- The GP told the consumer there was nothing he could do as the consumer had a stomach virus. The consumer was sent home with painkillers.
- The consumer again returned to the medical centre two days after his first visit. On this occasion, another GP examined him and diagnosed appendicitis. The consumer required immediate surgery for a ruptured appendix.
The Commissioner received the complaint from the Medical Council of New Zealand on 25 March 1998, and an investigation was undertaken. Information was received from the following people:
- The Consumer
- The Provider, General Practitioner
The consumer's medical records were obtained from the public hospital and reviewed. The Commissioner also sought advice from a general practitioner.
Information Gathered During Investigation
The consumer developed severe stomach pains and a high temperature in early February 1998. He went to the medical centre where he saw the GP. When the GP examined the consumer he noted that the consumer was feeling miserable, had a one to two day history of joint aches, had abdominal cramps and had been constipated for three days. The GP recalled that there was a possible tender mass in the consumer's left iliac fossa, but that in his view this was consistent with a diagnosis of constipation. The GP found no rebound tenderness or guarding, and prescribed microlax enemas. When the prescription was dispensed the consumer was given 36 enemas, of which he used four. The GP advised the Commissioner that he intended to prescribe three microlax enemas to the consumer "who did not have a chronic problem so any more would have been useless." The GP did not record the details of any medication prescribed. The dispensing pharmacy confirmed that 36 enemas were dispensed.
The consumer returned to the Clinic the next day as he continued to have abdominal pain and was not well. The GP examined him again. The consumer recalled suggesting to the GP that he thought he had appendicitis. The GP did not mention this in his explanation of the events. The GP noted the consumer's symptoms as "a fever/abdominal discomfort, still hot/cold, flushed and distressed, 2 x bowel motions, active bowel sounds, (abdominal) discomfort all over". No temperature was recorded. The GP advised the Commissioner that the lack of left iliac fossa tenderness, which was present on the previous day, and the fact that the consumer had viral symptoms made a diagnosis of appendicitis unlikely. He diagnosed a stomach virus and prescribed painkillers.
"…To insinuate that [the consumer] had an 'acute abdomen' needing hospitalisation on these 2 days is not correct. He had no 'usual' signs to suggest an 'acute abdomen' and abdominal pain being the only symptom?[The consumer] reported that the pain became a lot more severe [two days after his first visit to the GP]."
In response to my provisional opinion the GP advised that a rectal examination would not be of major use in making a diagnosis in this case, and that taking a temperature would not have helped him make a different diagnosis.
On the morning of the second day after the consumer had first visited the GP, the consumer remained sick and in acute pain. His mother telephoned the surgery to make an appointment. When the consumer and his mother arrived at the surgery the GP was not available. The consumer saw another GP. The other GP diagnosed probable appendicitis with rupture. He administered morphine for the pain and immediately arranged for the consumer's transfer by ambulance to a public hospital.
Upon arrival at the hospital the consumer was immediately taken to theatre for removal of a ruptured appendix. The discharge summary indicates that the consumer presented with four days of abdominal pain, associated nausea, vomiting, and a temperature of 39.5. The summary concludes:
"There was abdominal guarding, rebound tenderness and right iliac fossa pain. An open appendectomy revealed that [the consumer's] appendix had ruptured."
The consumer had a complicated post-operative period with continuing high spiking temperatures. An ultra sound taken three days post operatively confirmed that he had developed peritonitis. The consumer was treated with intravenous antibiotics for seven days.
Advice to Commissioner
The Commissioner's advisor stated:
"On perusal of the consultation notes that [the GP] made both on the [first visit] and [the second visit] I note that no mention is made of measurement of his temperature and likewise no mention is made of a rectal examination. ... A diagnosis of constipation and a viral illness together is an unlikely one and I feel that [the GP's] diagnosis of this was unreasonable. While sometimes it is difficult to diagnose appendicitis because of the signs and symptoms at the time being unusual, nevertheless a diagnosis of an acute abdomen should have been made and I believe [the consumer] should have been referred, if not on the[date in] February, certainly on the [following day], to the hospital for investigation. At that time it should have been apparent that there was certainly a possibility of appendicitis, even if the diagnosis was not entirely clear."
The adviser noted that the hospital medical records indicated that the consumer had a "pelvic appendix". This is where the appendix is situated in the pelvis, which sometimes makes the diagnosis of appendicitis less obvious. In closure the advisor noted:
"Nevertheless, in view of the obvious pain, high temperature and malaise that [the consumer] presented with on two days, the diagnosis of constipation and/or viral illness could not safely be entertained."
The Code of Health and Disability Services Consumers' Rights
Right to Services of an Appropriate Standard
2) Every consumer has the right to have services provided that comply with legal, professional, ethical, and other relevant standards.
4) Every consumer has the right to have services provided in a manner that minimises the potential harm to, or optimises the quality of life of that consumer.
In my opinion the GP breached Rights 4(2) and 4(4) of the Code of Health and Disability Services Consumers' Rights.
The consumer consulted the GP with severe abdominal pain and nausea on two consecutive days. The GP diagnosed constipation and prescribed enema. The following day the consumer's symptoms persisted unabated and his constipation could reasonably be excluded. While it is the GP's view that taking the consumer's temperature and performing a rectal examination may have been of little value in reaching a correct diagnosis. I accept the advice given by my independent general practitioner who noted that in view of the consumer's obvious acute pain and high temperature on both occasions, his temperature should have been measured and a rectal examination carried out, and following that, he should have been sent to hospital for assessment.
While it may not have been possible for the GP to diagnose acute appendicitis, in my opinion the lack of appropriate examination of the consumer's acute abdominal pain, the failure to record his prescription and the failure to refer him to hospital for investigation did not meet professional standards and did not minimise harm to the consumer.
I recommend the GP takes the following actions:
- Apologises in writing to the consumer for breaching the Code. This letter to be sent to me to forward to the consumer.
- Confirms that he has read and understands his obligation under the Code of Health and Disability Consumers' Rights, and that in a future case he will ensure an appropriate examination occurs.
A copy of this opinion will be sent to the Medical Council of New Zealand.
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