Clinical Matters Newsletter - August 2021 25 Aug 2021

Welcome to the August 2021 Edition of Clinical Matters

In this issue...

HDC Case: GP Fails in Care of Woman in Early Pregnancy	HDC Case: GP Failed to Properly Assess a Man Who Was Days Away From a Heart Attack
Live Panel Discussion: Investigating Symptoms of Lung Cancer: What's the Evidence?	Midland HealthPathways Update

HDC Case: GP Fails in Care of Woman in Early Pregnancy

Health and Disability Commissioner Morag McDowell today released a report finding a general practitioner (GP) in breach of the Code of Health and Disability Services Consumers’ Rights (the Code) for failures in their care of a woman in early pregnancy.

The woman, in her twenties, received a positive pregnancy test result. She experienced pain and bleeding, which are signs of a possible ectopic pregnancy. At around five weeks pregnant she saw her GP. The woman stated that she reported her pain to the GP, but the GP did not recall the woman mentioning pain and there is no mention of pain in the woman’s medical notes.

The GP arranged tests for urinary tract infection, sexually transmitted infections and rising pregnancy hormone level, but did not organise an ultrasound as she did not think it would add any helpful information given the woman’s early stage of pregnancy. The GP did not examine the woman’s abdomen or take her blood pressure or pulse, and did not offer any safety netting advice about what the woman should do if things got worse. When the woman’s hormone results were received, the GP appeared to have misinterpreted them as being reassuring.

Two days later, the woman presented to the emergency department of her local hospital with severe abdominal pain. The woman was diagnosed with severe internal bleeding secondary to a ruptured ectopic pregnancy. She required emergency surgery to remove a fallopian tube.

The Commissioner found several deficiencies in the care provided by the GP to the woman. In particular, she considered that the GP’s failure to directly inquire about whether the woman was experiencing pain in the initial appointment, and her failure to record the woman’s pain history, were departures from accepted practice.

"A common symptom of ectopic pregnancy is abdominal pain, and its presence alongside vaginal bleeding should raise a red flag for doctors to consider ectopic pregnancy," said Ms McDowell.

"It’s clear that the GP should have questioned the woman specifically about abdominal pain and documented her answer. Her failure to inquire about the pain directly impacted the course of the woman’s subsequent management."

Ms McDowell recommended that the medical centre undertake a review of all patients who experience PV bleeding in early pregnancy over the three month preceding the date of the report, to assess whether staff have actively questioned women about abdominal pain, documented this and conducted appropriate examinations. She also recommended that the GP attend an education workshop.

The full report of case 20HDC00477 is available on the HDC website.

Live Panel Discussion: Investigating Symptoms of Lung Cancer: What's the Evidence?

To register click here

Date: Thursday 9 September

Time: 6:00pm (AEST)

To access Lung Foundation Australia's lung cancer resources, information and support services for you and your patients, click here.

HDC Case: GP Failed to Properly Assess a Man Who Was Days Away From a Heart Attack

Deputy Health and Disability Commissioner Kevin Allan today released a report finding a locum GP in breach of the Code of Health and Disability Services Consumers’ Rights (the Code) for undertaking an inadequate assessment of a man in her care.

The man, in his sixties, had a history of diabetes, hypertension, and heart disease. He saw a locum GP because he’d been having indigestion and a lack of appetite for several months, had a fever and was exhausted.

The locum GP discussed with the man his symptoms, recent medical notes and medications, and diagnosed him with gastritis. She prescribed medication and advised him to take antacids if needed. A follow up appointment was made for a month’s time. Sadly, two days later the man collapsed at home from a heart attack and died shortly afterwards.

The Deputy Commissioner considered that the assessment undertaken by the GP was inadequate, in light of the man’s significant clinical history. The GP did not carry out appropriate questioning and investigation into his symptoms to exclude more serious cardiac conditions.
"The man presented with symptoms known to be related to atypical presentations of cardiac ischaemia," said Mr Allan.

"During the consultation, the locum GP did not ask the man questions to try to identify whether there were other possible diagnoses that might explain his symptoms or explore the cause of his exhaustion."

"She diagnosed the man with gastritis, despite being aware that this diagnosis didn’t explain his fever or headache, and that he had been taking Mylanta for several months, which hadn’t eased his symptoms," he said.

The Deputy Commissioner considered the consultation was a missed opportunity to understand whether the man required further medical treatment, and the locum GP did not provide services to the man with reasonable care and skill.

"This case highlights the importance of health providers considering other possibilities for presenting symptoms, and of considering a person’s clinical history and risk factors adequately," said Mr Allan.

Mr Allan recommended that the locum GP review the Best Practice Advocacy Centre guidance on the immediate management of acute coronary syndromes in primary care, and provide HDC with an analysis of typical and atypical presentations of angina, and what steps to take when a patient is presenting with cardiac symptoms.

He also recommended the locum GP review the Royal New Zealand College of General Practitioners standard "patient records meet requirements to describe and support the management of health care provided", and provide a written apology to the man’s family.

The full report on case 19HDC01874 is available on the HDC website.

Midland HealthPathways Update

New pathways for GPs on HealthPathways
The following pathways are now live on our HealthPathways site for you to use:

National Bowel Screening Programme (NBSP)
Nausea and Vomiting in Pregnancy

And remember there is up-to-date information on all matters Covid-19 for primary care on Health Pathways, including national as well as local information.

HealthPathways is a collection of management guidelines specifically tailored to primary care. Our GP Liaison team is in the process of 'localising' these pathways to the Bay of Plenty, i.e, making them relevant to GPs and other primary care providers specifically in the Bay of Plenty. You'll find valuable pointers on history, examination, treatment and of course when and how to refer patients on to other services. These pathways will, over time, be replacing the Bay Navigator pathways.