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NZ Professional support and expert advice
from your leading medicolegal journal
CASEBOOK
VOLUME 24 ISSUE 1
MAY 2016
This issue…
FROM THE CASE
FILES ACHIEVING SAFER
AND RELIABLE
Our latest collection
of case reports
RISK ALERT –
MEDICATION
ERRORS
PRACTICE
AND SAFER
PRESCRIBING IMPROVE YOUR SAFETY
Common problem AND QUALITY WITH OUR
NEW WORKSHOP
areas in prescribing
A FAMILY MATTER
The risks of treating PAGE 6
friends and family
MORE THAN DEFENCE
More support for your
professional development
E-LEARNING
DEVELOP YOUR SKILLS 97%
AT A TIME AND A PLACE OF USERS WOULD
TO SUIT YOU. RECOMMEND
PODCASTS
CASE REPORTS
Medical Records
INTERACTIVE
MODULES Medication Errors and
Safer Prescribing
Professionalism and
Ethics
NEW NT
CONTE
FOR
2016
SIGN UP TODAY FREE TO EARN
medicalprotection.org/elearning MEMBERS CPD
elearning@medicalprotection.org
2291/GEN: 04/16
FEATURES
WHAT’S INSIDE…
06 Achieving safer and reliable practice
Medical Protection’s Dr Suzy Jordache and Sam McCaffrey look
at how a new workshop for members is making for a more reliable
healthcare experience.
08 A family matter
Medical Protection’s Pippa Weeks examines the legal and ethical
considerations of treating friends and family.
09 M
edical professionals and the Vulnerable
Children Act
New safety checks on workers who have regular contact with
children have started to be phased in. Victoria Knell, Senior Solicitor
at DLA Piper, explains what this means for medical professionals.
FACTS AND OPINION
04 Welcome
Dr Marika Davies, our new Editor-in-Chief of Casebook, comments on
some topical issues affecting healthcare.
05 R
isk alert – medication errors and
safer prescribing
Medical Protection Clinical Risk Facilitator Dr David Coombs
examines two cases that demonstrate common risks associated with
prescribing.
11 From the case files
CASE REPORTS Every issue... Dr Richard Stacey, Senior Medicolegal Adviser, looks at what can be
learned from this edition’s collection of case reports.
12 Missed meningitis
13 Problematic anaesthetic 25 Over to you
14 Failure to follow specialist advice A sounding board for you,
15 Undescended testis the reader – what did you
think about the last issue of
16 Diagnosing pneumonia out of hours Casebook? All comments
18 T
ragic outcomes don’t always and suggestions welcome.
Opinions expressed herein are those of the authors.
equal negligence Pictures should not be relied upon as accurate
19 Stretch marks and steroids 26 Reviews representations of clinical situations. © The Medical
Protection Society Limited 2016. All rights are reserved.
20 Lost opportunity In this issue we review two
ISSN 1740 4409
Casebook is designed and produced twice a year by the
21 D
ifficult matters of opinion books on topical subjects. Communications Department of the Medical Protection
Society (MPS). Regional editions of each issue are mailed
and recall to all MPS members worldwide.
22 Failure to diagnose pre-eclampsia GLOBE (logo) (series of 6)® is a registered UK trade mark in
the name of The Medical Protection Society Limited.
23 If it is not recorded… MPS is not an insurance company. All the benefits of
membership of MPS are discretionary as set out in the
24 O
ne in the eye for spurious Memorandum and Articles of Association. MPS is a
registered trademark and ‘Medical Protection’ is a trading
litigation name of MPS.
Cover: © Chunumunu/iStock/thinkstockphotos.co.uk
Get the most from Visit our website for publications,
news, events and other information:
your membership… medicalprotection.org
EDITORIAL TEAM
WELCOME
Dr Marika Davies Sam McCaffrey
EDITOR-IN-CHIEF EDITOR
Dr Marika Davies
EDITOR-IN-CHIEF
Rebecca Imrie
EDITORIAL CONSULTANT
I
am delighted to welcome you to this latest edition
of Casebook and my first as Editor-in-Chief. I would
EDITORIAL BOARD like to express my thanks to my predecessor, Dr
Dr Muiris Houston, Mark Jordan, Dr Gordon McDavid, Shelley McNicol, Nick Clements. For many years Nick has made an enormous
Dr Sonya McCullough, Dr Jayne Molodynski, Dr Clare Redmond, contribution to both Casebook and to the work we do on behalf
Antony Timlin, Dr Richard Vautrey of members, and his considerable knowledge and experience
have been invaluable resources. Fortunately he has not gone
far, and we wish him all the best in his new role within Medical
PRODUCTION Protection.
Philip Walker, Production Manager
Allison Forbes, Lucy Wilson, and Spiral, Design Having been a medicolegal adviser at Medical Protection for
Southern Colour, Print over 12 years I have had the privilege to advise and assist many
doctors going through difficulties in their professional lives. I am
very aware of the stress and anxiety that doctors experience
CASE REPORT WRITERS when they are the subject of criticism or an investigation,
and the impact this can have on them both personally and
professionally. Helping doctors to avoid such difficulties in the
Dr John P Adams Dr Rachel Birch first place through education and awareness of risk is one of
the key aims of Casebook, and I hope to continue the tradition
of publishing informative, educational articles and case reports
that help to improve practice and prompt discussion.
Dr Anna Fox Dr Bobby Nicholas
As part of our commitment to education we have launched a
new workshop in New Zealand on ‘Achieving safer and reliable
practice’, to help members lower their risk. On page 6 we take
Dr Janet Page Prof Carol Seymour a look at what the workshop involves and provide some hints
and tips on achieving safer practice.
Treating friends and family may seem convenient, but can be
fraught with difficulties. We examine the issue on page 8.
The case reports in this edition have a particular focus on
conditions that can lead to lead to difficulty. While some of
these medical conditions may not be that common, they can
lead to significant disabilities for the patient, unless diagnosed
early and appropriate action taken. One of the challenges
for clinicians is identifying those patients that require further
investigation in order to establish or rule out serious underlying
pathology. As the cases demonstrate, good documentation is
essential in order to justify your clinical decisions if there is an
adverse outcome.
I hope you enjoy this edition. We welcome all feedback, so
Please address all correspondence to:
please do contact us with your comments or if you have any
ideas for topics you’d like us to cover.
Casebook editor
Medical Protection Society
Dr Marika Davies
Victoria House
Casebook Editor-in-Chief
2-3 Victoria Place
marika.davies@medicalprotection.org
Leeds LS11 5AE
United Kingdom
casebook@medicalprotection.org
FEATURE
RISK ALERT
MEDICATION ERRORS AND SAFER PRESCRIBING
GP and Medical Protection Clinical Risk Facilitator Dr David Coombs examines two cases
that demonstrate common risks associated with prescribing
P
rescribing is one of the greatest been coded as “medication review done”. He A significant event analysis at the practice
risk areas for all clinicians and had initially been prescribed hydrocortisone revealed that Dr D had not accessed the
can be particularly hazardous for 1% ointment for his face but had stopped patient notes before giving advice. There was
the inexperienced doctor. It is fraught with ordering this as well as his emollients when nothing in the clinical notes to record the
potential pitfalls, ranging from transcription he found the stronger steroid more effective. discussion between the nurse and Dr D.
errors and inadvertent dosage mistakes to The prescriptions for fluocinolone cream had
overlooked drug interactions, allergies and simply stated “apply twice daily”. LEARNING POINTS
side effects, the consequences of which may • Distractions and interruptions are a
be profound both for the patient and the LEARNING POINTS common cause of error.
prescriber. • A change of GP practice is a good
opportunity to review all medication. • A study in the UK has shown that
It is imperative that you have a good vaccination errors are one of the most
knowledge of the pharmacology and the • Medication reviews should encompass frequently reported medication safety
legislation surrounding drugs, and any all items. incidents reported in primary care1.
protocols and controlled drug routines that
apply within your workplace – if unsure, ask. • Include relevant information on the • When prescribing or giving advice about
prescription, such as the problem being a new or unfamiliar drug, be prepared
To help members control their prescribing treated and any monitoring requirements. to look up information on your clinical
risks Medical Protection has developed a new This will appear on the label once the record system, in a formulary or in specific
online module on the subject, which can be medication is dispensed and may improve guidelines as appropriate.
found on our e-learning platform, Prism. adherence to treatment. For example,
“apply twice daily to body, arms and legs for • Make contemporaneous records of all
Below are two case reports highlighting some severe eczema only”. contacts/discussions with colleagues
common potential hazards. about patients.
• Consider restricting the number of issues
CASE 1 allowable for certain drugs, such as potent • Administration of a routine vaccination
topical steroids, before a review. is not urgent and, although inconvenient
Mr A registered with a new GP practice and for the patient, it may be safer to rebook,
requested a repeat prescription for his regular • In some cases it may be preferable not allowing time to check facts – particularly
medication, which included fluocinolone to add as repeat prescription until clear if, as here, the patient had a short
0.025% cream (a potent topical steroid). He that the condition is responding as appointment earmarked just for the flu
was asked to attend for a GP appointment expected. vaccination.
with Dr B, who immediately noticed the
patient’s “bright red shiny face”. Mr A • Consider the use of patient information REFERENCES
explained that he had suffered from asthma leaflets to explain the management of 1. National Reporting and Learning System. NPSA.
Medication Incidents in Primary Care. Quarterly Data
and eczema for many years and that he had chronic conditions more clearly. summary issue 7 2008. National Patient Safety Agency
started using the fluocinolone on his face
about two years earlier when his eczema had CASE 2 The cases mentioned in this article are fictional and are
used purely for illustrative purposes.
been bad. Although the eczema on his body
and limbs had cleared up, he found that as Mr C was on long-term immunosuppressive
soon as he stopped using the steroid on his treatment when he visited his general
face it became very uncomfortable, so he practice for his annual flu vaccine. He asked To take part in the Medical Protection
continued to use it. if he could also be given the new shingles Medication Errors and Safer
vaccine. The nurse said he was not sure and Prescribing e-learning module and
Dr B discussed the risks of continuing to use would check with one of the GPs. He waited
the potent steroid on his face and referred outside one of the consulting rooms and
help lower your prescribing risk, visit:
him to a local dermatologist who initiated a quickly popped in between patients. Dr D
regime to reduce gradually the strength of was already running behind with her surgery medicalprotection.org
topical steroid used on the face. After four and after a brief thought said, “Yes, that
months Mr A found he no longer needed to would be fine.” and click on the e-learning link.
use any topical steroid on his face.
Mr C was given the vaccine and unfortunately
Discussion with Mr A and review of his developed an atypical herpes zoster
records revealed that although he had infection. A few months later a complaint and
attended for reviews at his previous GP, these subsequently a claim were made against the
had been at the asthma clinic. His records had GP practice.
CASEBOOK | VOLUME 24 ISSUE 1 | MAY 2016 | medicalprotection.org 5
FEATURE
ACHIEVING SAFER AND
RELIABLE PRACTICE
Medical Protection’s Dr Suzy Jordache and Sam McCaffrey look
at how a new workshop for members is making for a more reliable
healthcare experience
WHAT LEVEL IS ACHIEVABLE?
S
afe healthcare requires both the Processes and systems
expert knowledge and technical Research suggests that implementation rates Inadequate:
skill of healthcare professionals as in healthcare for standard procedures that
well as reliable delivery and application of impact on patient safety are between 50% • Structured decisional support and
that knowledge and skill. and 70%, or >10-1. checking tools.
In the new Medical Protection workshop, Other industries such as aviation and nuclear • Measurement, feedback and
Achieving Safer and Reliable Practice, power have achieved reliability levels of accountability mechanisms.
reliability is defined as minimal unwanted 10-6 in critical processes. In healthcare,
variability in the care we have determined anaesthetics has been successful in achieving • Briefing and simulation.
our patients should receive. Any figure below this level of reliability during the induction of
80% reliability would be termed ‘chaos’ anaesthesia. This and other reliable practices, • Environmental design and control.
in other safety critical sectors, and yet in such as blood transfusions and pathology
healthcare we regularly report ‘success’ labelling, can inspire and lead the way for • Equipment design.
rates of 80% or lower. For example, the all of us, whether practising in primary or
latest national data1 is that in October 2015 secondary care. ALWAYS CHECKING
DHBs reached and sustained handwashing In order to mitigate the risks from these
rates at or above 80%. HUMAN FACTORS factors Medical Protection advocates the
The science of human factors examines the AlwaysChecking™ approach, which offers
Examples of the variation in reliability in relationship between people and the systems five manageable, evidence-based steps to
healthcare are readily available. In New with which they interact, with the goal of raise reliability in any healthcare setting:
Zealand the Health Quality and Safety minimising errors. In healthcare, human
Commission’s Atlas of Healthcare Variation2 factors knowledge can help design processes
has many examples of variation between that make it easier for doctors and nurses to
DHB regions in everything from post- do the job correctly.
operative infection, tonsillectomy rates and Moving to 10-2
medication after cardiac events to glycaemic Some of the factors that have been identified The MPS AlwaysChecking™ approach
control for diabetes. In the NHS the Health as having the potential to impede human
Foundation’s report in 20103 found that in performance include:
nearly one in five operations equipment was Principle Strategy
faulty, missing or used incorrectly; around People We always check:
one in seven prescriptions for hospital • Perceptual deficits under stress.
inpatients contained an error; and full clinical each other and
information was not available at just under • Fatigue; welcome being Speaking up
one in seven outpatient appointments. checked
The report also commented on the wide • physical,
variations in reliability between and within • decisional. what we’ve agreed
Checklists
organisations. should be done
• Poor interpersonal communication;
HOW RELIABILITY IS QUANTIFIED message sent is Repeatback/
Reliability is often expressed in terms of • transmission/reception, message received Readback
failure rate as a power of 10. For example, • challenge.
a procedure that is reliable nine times out we know how to Briefing and
of ten fails 10% of the time, or has 10-1 • Poor understanding of the nature of work together Simulation
reliability. A procedure that fails 20% of the human error;
time has a reliability of >10-1. always means Measurement and
• causes, always Accountability
Systems that fall below 10-1 reliability are • extent,
generally considered ‘chaotic’. • the weakness of 10-1 strategies in
prevention.
6
FEATURE
Perhaps the most important strategy It resulted in the infection rate falling from
is that of ‘speaking up’ – safe cultures 11.3/1000 to 0/1000 catheter days, as
Example: Handwashing
train and insist on respectful assertive
communication. In healthcare, we often find
well as 43 infections and eight deaths
being prevented.
programme
that following an error, one member of the
team had ‘seen it coming’ but felt unable to The workshop includes a guide on how to
Year Handwashing Rate
say anything. There are complex reasons for develop effective checklists and implement
this and simple steps by individual clinicians them in organisations.
2009 58%
can transform safety.
MEASUREMENT AND 2010 80%
Speaking up is only possible in a culture ACCOUNTABILITY
that accepts that everyone will make Another key aspect of the AlwaysChecking™ 2011 92%
mistakes. In many teams the perceived approach is “Measurement and
negative consequences of speaking up can Accountability”. Within many organisations
be greater than those of not speaking up. and teams there will be some clinicians who • 30% reduction in serious hospital
Explicitly telling others of your expectation do not conform to agreed safety procedures. infections.
that they will speak up and ‘have your back’ Allowing ‘special rules’ for some is toxic and
and thanking anyone who challenges you – can sabotage success. • Estimated annual net savings of
especially when they are wrong – can help US$4.5m.
change this perception. Challenging these individuals can be difficult,
but without doing so high reliability and • Tenfold reduction in ICU central line
Engaging with those in your team who are safety cannot be achieved. The success story infection rate (now one quarter of
reluctant to speak up is also essential. This from Vanderbilt University Hospital system national benchmark).
may require training to ensure that the in the USA demonstrates the importance of Vanderbilt U.M.C
necessary skills are taught and learnt. measurement, feedback and accountability5
– highlighting the power of insisting that
CHECKLISTS “always means always” around handwashing
The use of checklists in healthcare has
been demonstrated in numerous studies to The results achieved in 2009 (>10-1) were
improve reliability and outcomes for patients, achieved using strategies based on individual
yet they are still resisted by some in the memory, diligence and vigilance. In 2010 the
profession and are often hotly debated during centre moved to a detailed monitoring and
the workshop. individualised clinician and team benchmark
feedback process, leading to 10-1 levels
Some of the benefits of using a checklist: of reliability.
• Reduce cognitive work. Since 2011 the level of compliance has been
maintained (and even increased again) to 10-2.
• Facilitate concentration on first order The benefits to patients, in terms of morbidity
concerns. and mortality reduction, along with the
economic benefits to the hospital and the
• Critical in preventing “never events”. decreased risk of complaint and claim for the
clinicians employed by Vanderbilt, are a
• Change the culture of a team; testament to the value of measurement and
accountability in achieving 10-2 reliability.
• validate the importance of a safe
process,
• empower team members to challenge.
In one example the successful REFERENCES
implementation of a checklist saved lives
1. Hand Hygiene New Zealand National Hand Hygiene
and millions of dollars by eliminating central
WORKSHOP
Performance Report 1 July 2015 to 31 October 2015,
venous line infections4. Health Quality and Safety Commission
2. Health Quality & Safety Commission | Atlas of Healthcare
Variation. Available at: hqsc.govt.nz/our-programmes/
The intervention involved the education of health-quality-evaluation/projects/atlas-of-healthcare-
staff, creating a dedicated catheter insertion variation/ [Accessed February 22, 2016] To book your place on a workshop, visit
3. The Health Foundation, How Safe are Clinical Systems?
cart, daily assessment as to whether Primary research into the reliability of systems within seven medicalprotection.org and click on
catheters could be removed, implementing a NHS organisations and ideas for improvement. May 2010 ‘Education and Events’.
4. Berenholtz S et al, Elminating catheter-related bloodstream
checklist to ensure guidelines for preventing infections in the intensive care unit, Crit Care Med
infections were followed, and training and 32(10:2014-2020 (2004)
5. Vanderbilt University Medical Centre, VUMC HH Program
empowering nurses to challenge colleagues Observer Recognition Nov 2012 [Powerpoint slides],
if they were not following the checklist. VUMC (2012) Available: mc.vanderbilt.edu/documents/
handhygiene
CASEBOOK | VOLUME 24 ISSUE 1 | MAY 2016 | medicalprotection.org 7
FEATURE
A FAMILY MATTER
MEDICAL PROTECTION’S PIPPA WEEKS EXAMINES THE LEGAL AND
ETHICAL CONSIDERATIONS OF TREATING FRIENDS AND FAMILY
E
very doctor has probably faced intimate examinations, and the patient may
the dilemma where someone not feel comfortable disclosing intimate or
they know asks for their medical embarrassing issues to close relations. If the
advice. Sometimes it is an informal comment patient is then likely to attend a separate
they are seeking, and sometimes it is a more GP as well, the risk of disjointed care and
serious commitment. Either way, doctors incomplete records becomes significant. CASE STUDY
should be aware of the Medical Council of
New Zealand’s (MCNZ) guidance that says The patient may also feel unable to refuse Dr E’s colleague told him he was
you should avoid treating anyone with whom treatment, or to seek an alternative opinion. feeling low but didn’t feel able
you have a close personal relationship. These issues are particularly true for children to talk to his GP or anyone else
or young people, who may not wish their about it. Reluctantly, Dr E agreed
THE GUIDANCE relations to know details of their lives and to prescribe him a course of anti-
The MCNZ has published a statement on who are not able to seek alternatives. depressants. The colleague’s mood
providing care to “those close to you”. It improved and, when he was due to
states: “The Medical Council recognises that Maintaining trust and a confidential move jobs, he reassured Dr E that
there are some situations where treatment relationship between doctor and patient he would be fine and would seek
of those close to you may occur but this becomes significantly challenging when the medical care elsewhere. A few
should only occur when overall management doctor and the patient belong to the same weeks later Dr E was devastated to
of patient care is being monitored by an family or group. For example, a father who is hear that his former colleague had
independent practitioner. Wherever possible doctor to his daughter may feel pressured to attempted suicide. The colleague’s
doctors should avoid treating people with discuss her health with her mother. Although partner reported Dr E to the MCNZ.
whom they have a personal relationship doctors might feel that this could never Dr E sought assistance from Medical
rather than a professional relationship. happen to them or their family, it is far too Protection, and his case was
Providing care to yourself or those close to important a scenario to dismiss. assigned to a medicolegal adviser
you is neither prudent nor practical due to who assisted him in providing an
the lack of objectivity and discontinuity PRESCRIBING explanation for his actions. At the
of care.1” Although prescribing for family or friends may end of its investigation the MCNZ
not be illegal, it can be risky. In order to have concluded the case with a warning,
Although it is recognised that there are a dispassionate appreciation of the medical with a recommendation that Dr E
some situations in which it might be diagnosis and treatment plan, the prescriber undergo educational courses on
unavoidable, such as a solo practitioner should not be emotionally involved with the prescribing and documentation.
in a remote community, or in an emergency patient. If the patient is seeking medical
situation, the MCNZ takes the view that advice from both a family member and a
the standard of care and the professional separate GP, the drugs prescribed may result
relationship between doctor and patient in being duplicated, or even contraindicated. The cases mentioned in this article are fictional and are used purely
is adversely affected if there is also a Disjointed treatment plans and duplicated or for illustrative purposes.
personal relationship, and should be avoided incomplete records may result in inadequate
wherever possible. or dangerous health care.
THE ETHICS
Many doctors would trust themselves above
The patient may also require review or
monitoring that could be missed if they are
WHAT DO YOU
all others to provide good care to their
loved ones, but it is hard to imagine that the
not seeing their regular doctor.
THINK?
objective standard of clinical care would not Treating those close to you may be
be impacted by an emotional relationship to tempting, and it is often difficult to refuse, We want to hear from you. Send your
the patient. Doctors are always interested but you should approach such requests with comments to:
in the continued health and treatment of great caution and be prepared to justify casebook@medicalprotection.org
their patients, but the stakes are never your actions.
higher than when the outcome would
personally affect the practitioner and their REFERENCES
family. Additionally, the doctor may not feel 1. Medical Council of New Zealand, Statement on providing care
able to ask sensitive questions or perform to yourself and those close to you, June 2013.
8
FEATURE
MEDICAL PROFESSIONALS AND THE
VULNERABLE CHILDREN ACT
New safety checks on workers who have regular contact with children have started to be phased in.
Victoria Knell, Senior Solicitor at DLA Piper, explains what this means for medical professionals
T
he Vulnerable Children Act 2014 applies from 1 July this year (2016) and they
introduces the vetting of people have until 1 July to apply for an exemption. SAFETY CHECKS
in the workforce who have regular The checks that practices will be required
contact with children1 where a parent or If a practice or organisation becomes aware to undertake are:
guardian of the child may not be present. that a core children’s worker has a conviction
GPs, locums, nurses and support workers will for a specified offence, they must suspend New workers
all be considered children’s workers under the worker, while continuing to pay them. 1. Identity confirmation of the proposed
the Act and will be required to be screened When suspending a worker the employer children’s worker.
by the organisation they work for. must specify the period of suspension (which 2. Collection of information including
must not be less than five working days), the children’s worker’s work history,
ORGANISATIONS inform the worker of the reason behind the references and:
If a hospital or medical practice receives any suspension and ask them to respond. (a) an interview which should include
amount of public funds they will be required open questions and be conducted
to ensure safety checks on the workers they When a worker is suspended their by people confident to ask questions
employ, but those in private practice who employment cannot be terminated until about child safety; and
receive no state funding are not covered. at least five working days after the (b) verification that the proposed worker
suspension begins. is registered with the appropriate
Self-employed practitioners and locums, professional body.
however, are covered and the Ministry Workers who are terminated due to the 3. Police vetting. This can take up to 20
of Health is currently establishing an workforce restriction are not entitled to days to complete and results must be
independent screening service to have any compensation or other payment and considered before a proposed worker
the appropriate checks completed for the termination will be deemed to be commences work.
such individuals. justifiable dismissal. 4. An evaluation of all the information
obtained and an assessment of any risk
CORE AND NON-CORE OFFENCES UNDER THE ACT of employing the proposed children’s
CHILDREN’S WORKERS An organisation that does not ensure each worker, including consideration of
The Act makes a distinction between “core child’s worker is safety checked and re- whether the role is for a core children’s
children’s workers” and “non-core children’s checked within three years will be liable on worker or non-core children’s worker.
workers”. The main difference between conviction to a fine of up to $10,000.
the two is that the Act comes into force Existing workers
earlier for core children’s workers who are An organisation that employs a person There are fewer checks required for those
also subject to the workforce restriction convicted of a specified offence and who children’s workers who are already employed
(explained below). does not hold an exemption will be liable on or engaged by a specified organisation. For
conviction to a fine of up to $50,000. an existing worker the specified organisation
A core children’s worker is someone who, is required to undertake requirements 1,
when present with a child, is the only The Act’s obligations are likely to be 2(b), 3 and 4 above.
children’s worker present or is the children’s particularly onerous on medical practices
worker who has primary responsibility for, and self-employed practitioners who receive The information obtained for each children’s
or authority over, the child present (GPs state funding. Organisations should create worker must be updated every three years.
and nurses will likely be considered core a child protection policy and maintain
children’s workers). records about the safety checking process REFERENCES
as compliance may be checked. If you are
1. A child is a person under the age of 17 years and who is not,
A non-core worker is a children’s worker who concerned about how the Act might impact or has not been, married
does not fit the definition of core children’s you and your practice, contact Medical 2. A full list of specified offences can be found in Schedule 2 of
the Act
worker (administrative and general practice Protection at: advice@mps.org.nz. 3. Information regarding the exemption can be obtained by
staff will likely be considered non-core emailing Core_Worker_Exemption@msd.govt.nz
children’s workers).
KEY DATES
THE WORKFORCE RESTRICTION
People who have been convicted of offences 1 July 2015 – all new core children’s workers must be safety checked before starting with
involving children, violent behaviour and a specified organisation.
sexual offending2 will face restrictions and 1 July 2016 – all new non-core children’s workers must be safety checked before starting
will be required to apply for an exemption3 if with a specified organisation.
they wish to be a core children’s worker. 1 July 2018 – all existing core children’s workers must have been safety checked.
1 July 2019 – all existing non-core children’s workers must have been safety checked.
For core children’s workers starting a new
job, the restriction already applies. However, Children’s workers are required to have their checks updated within three years of the
for those already employed, the restriction initial checks.
CASEBOOK | VOLUME 24 ISSUE 1 | MAY 2016 | medicalprotection.org 9
MORE THAN DEFENCE
More support for your
professional development
ACHIEVING NEW
SAFER AND
RELIABLE
This is a topic
that is a long
time overdue –
PRACTICE
I have had a
little awakening
CONTENTS INCLUDE
Implement processes for safer, more reliable care
Avoid adverse outcomes and patient dissatisfaction
Identify factors that impact on human performance
Reduce your risk of complaints
Explore real life examples of high reliability
BOOK TODAY and find out more
medicalprotection.org FREE TO EARN
MEMBERS CPD/CMU
education@mps.org.nz
0800 225 5677
AVAILABLE AT LOCATIONS THROUGHOUT NEW ZEALAND
2287/NZ: 04/16FROM THE CASE FILES Want to join the discussion about this
edition’s case reports? Visit
medicalprotection.org and click on
Dr Richard Stacey, Senior Medicolegal Adviser, the “Casebook and Resources” tab.
introduces this edition’s case reports
Think beyond the common
W
hen I was at medical school, I recall being clinicians is identifying those patients that require
admonished for suggesting an esoteric further investigation (and/or treatment) in order to
cause for a presentation of acute renal establish or rule out serious underlying pathology and
failure (or acute kidney injury as it is now known), arranging for that investigation (and/or treatment)
under the explanation from the consultant that to be undertaken within a reasonable time frame
common things are common and that when (which, depending on the circumstances, may be
providing a differential diagnosis, I should start on an emergency basis). There is an abundance
by providing a list of the common causes. Then, of diagnostic algorithms, standards and guidance
without a hint of irony, the consultant suggested available, and whilst it is not always easy to access
that I might wish to see a patient who had been them in the midst of a consultation, if there is an
admitted overnight with acute renal failure as a adverse outcome, your care will be judged to the
consequence of Wegener’s Granulomatosis. relevant standards and guidance (that prevailed at
the time of the incident).
This edition of Casebook highlights a number
of cases in which allegations have arisen as a In circumstances when you have made a diagnosis of
consequence of a missed and/or delayed diagnosis a common benign and/or self-limiting illness, it is useful
of serious underlying pathology: in the case of Mr to ask yourself the following check questions:
B it was alleged that the severity of his symptoms
was underestimated and that a home visit should 1. Have I advised the patient of red flag symptoms to
have been arranged; there are two paediatric look out for and explained what they should do in the
cases in which the allegations related to a missed/ event that these develop?
delayed diagnosis of meningitis/meningococcal
septicaemia; there is a case in which there 2. H
ave I informed the patient as to what should
was a missed diagnosis of pre-eclampsia with prompt them to return for review?
catastrophic consequences for the baby; and there
is a case in which there is an unusual presentation 3. If the diagnosis subsequently turns out to represent
of renal disease, which was subsequently serious underlying pathology, would I be in a position
complicated by a subarachnoid haemorrhage. to justify not making (or contemplating) that
diagnosis based on the information available to me?
The difficulty that a clinician faces when
assessing a patient is that, by definition, Check questions 1 and 2 amount to the provision
common things are common and (usually, but of safety-netting advice and if the answer to check
not always) are either benign and/or self-limiting question 3 is ‘no’ then this should prompt consideration
in their nature. For example, most children who as to whether further investigation is indicated.
present with coryzal symptoms will not have
serious underlying pathology; most pregnant I hope that you find both the cases and the above
patients who develop ankle swelling will not suggestions thought-provoking and draw your
have pre-eclampsia; most patients who present attention to the fact that the cases have common
with headache will not have serious underlying themes relating to both communication and record-
pathology etc. One of the challenges for keeping.
What’s it worth? HIGH NZ$1,000,000+
SUBSTANTIAL NZ$100,000+
Since precise settlement figures can be affected by issues that are
not directly relevant to the learning points of the case (such as the MODERATE NZ$10,000+
claimant’s job or the number of children they have), this figure can
LOW NZ$1,000+
sometimes be misleading. For case reports in Casebook, we simply give a
broad indication of the settlement figure, based on the following scale: NEGLIGIBLECASE REPORTS
© Ilya Andriyanov/Hemera/thinkstockphotos.co.uk
MISSED MENINGITIS
SPECIALTY GENERAL PRACTICE
THEME SUCCESSFUL DEFENCE
J
C was a 20-month-old boy who
had been up all night with a fever.
It was the weekend so his mother
rang the out-of-hours GP. She explained that
his temperature was 39.4 degrees and that
he was clingy and sleepy. Dr R assessed him severe sensorineural hearing loss. Despite excellent initial recovery and the minor
at the out-of-hours centre and documented hearing aids JC had delayed speech and x-ray changes it was difficult to explain
that there was no rash, vomiting or language development. His mother was the alleged hip symptoms as children with
diarrhoea. His examination recorded the upset because he struggled with poor coxa magna generally have no symptoms
absence of photophobia and neck stiffness. concentration at school and found it difficult even with contact sports. He thought that
He stated “nothing to suggest meningitis”. to interact in groups. JC would have a lifetime risk of needing
Examination of the ears, throat and chest hip replacement of 12-20% due to past
were documented as normal. He noted JC’s mother made a claim against Dr R, septic arthritis.
that his feet were cool but he appeared alleging that he failed to diagnose meningitis
hydrated. Dr R diagnosed a viral illness and admit her son. She felt that if his The ENT consultant concluded that JC
and advised paracetamol and fluids. He meningitis had been treated earlier his would need to use hearing aids for the
advised JC’s mother to make contact if hearing could have been saved and he would rest of his life. He felt that his speech and
he developed a rash, vomiting, or if she not be at risk of arthritis in his hip in later life. language development had also been
was concerned. compromised by poor hearing aid usage.
EXPERT OPINION
JC’s mother felt reassured so she took Medical Protection obtained expert opinion In response to the Letter of Claim from the
him home and followed the GP’s advice. from a GP, a professor in infectious diseases, claimant’s solicitors, Medical Protection
JC remained tired and off his food over an orthopaedic surgeon and a consultant issued a letter of response denying liability
the next two days. The following day he in ENT. based on the supportive expert opinion and
began vomiting and mum could not get his the claim was discontinued.
temperature down. He seemed drowsy and The GP thought Dr R had made a
was just lying in her arms. She took him comprehensive examination of a febrile
straight to A+E. child and had demonstrated an active
consideration of the possibility of
He was very unwell by the time he was meningitis. He commented that the
Learning points
assessed in A+E. The doctors noted that features of many childhood viral illnesses
• BPAC have
he was pale, drowsy, and only responding are indistinguishable from the very early a useful traffic
for identif ying light system
to pain. His temperature was 38 degrees stages of meningitis. He noted that Dr R risk of serious
feverish childre illness in
and his pulse was 160bpm. A diagnosis had advised JC’s mother to make contact if n under five1.
other clinical sig Along with
ns, it requires
of “sepsis” was made. Full examination he deteriorated. He was a little critical of pulse, respirato GPs to check
ry rate, tempe
revealed neck stiffness and he went on to Dr R for not recording JC’s vital signs such capillary refill
time in order to
rature and
have a lumbar puncture. This confirmed as pulse and temperature. He felt this was them into grou categorise
ps of low, med
meningitis with Haemophilus influenzae. an important part of determining a child’s risk of having ium or high
serious illness.
risk of having a serious illness. • Safety nett
ing is an impo
JC was treated with IV fluids, ceftriaxone consultation. rtant part of a
In this case Dr
and dexamethasone and showed great The professor of infectious diseases mother to cont R advised the
act services ag
improvement. Four days later he developed thought that JC did not have meningitis deteriorated. ain if he
This helped M
defend his case edical Protectio
a septic right hip needing aspiration when he saw Dr R but was likely to be in . n
and arthrotomy. The aspirate revealed the bacteraemic phase of the illness. This • In some case
s claims can be
Haemophilus influenzae. A month later he phase shares features with many other years after th brought many
e events. This
was assessed at a fracture clinic and was more trivial infections. He explained that note-keeping makes good
essential as m
will often be th edical records
walking unaided and fully weight-bearing. Haemophilus influenzae meningitis can e only reliable
occurred. record of wha
An x-ray eight years later showed that the present in an insidious fashion over t
REFERENCES
right femoral capital epiphysis was slightly several days. He felt that the vomiting
larger than the left. His mother claimed that three days later may have signified 1. Identifying
the risk of serio
us illness in ch
he complained of daily hip pain, giving way cerebral irritation due to meningitis. BPAC, July 20
10: bpac.org.n ildren with fev
er,
z/BPJ/2010/
July/fever.as
and morning stiffness. px
AF
The orthopaedic surgeon noted the
Two months after his illness JC had a minor x-ray abnormalities in JC’s right
hearing test that showed moderately hip. He felt that given the patient’s
12CASE REPORTS
© Ilya Andriyanov/Hemera/thinkstockphotos.co.uk
PROBLEMATIC
ANAESTHETIC
SPECIALTY ANAESTHETICS
THEME CONSENT/INTERVENTION
AND MANAGEMENT
SUBSTANTIAL
M
rs B was a 57-year-old lady with Dr S then administered atracurium 30mg needle was in proximity to nerve tissue.
a past history of breast cancer and Mrs B was ventilated for the duration However, Dr M did concede that there was
treated with mastectomy and of the operation. The operation was largely a body of responsible anaesthetists who
adjuvant therapy. She re-presented to her uneventful apart from modest hypotension, would support the notion of performing
consultant breast surgeon, Mr F, three years which Dr S treated with boluses of ephedrine a paravertebral block with the patient
after the original surgery with a worrying 2cm and metaraminol. anaesthetised.
lump in the vicinity of her mastectomy scar.
Mr F recommended an urgent excision biopsy At the end of surgery, Dr S reversed the 3. He was critical of Dr S’s decision to keep
of the lump under general anaesthetic. neuromuscular blockade and attempted to persisting with the block when he was
wake Mrs B. However, Mrs B’s respiratory struggling to locate the correct needle
On the day of surgery, Mrs B was reviewed effort was poor and she was not able to move position. He felt that Dr S should have
by consultant anaesthetist Dr S. She told her limbs. Dr S diagnosed an epidural block abandoned the block or called for help.
Dr S that she had been fine with her previous caused by spread of the local anaesthetic. He He also concluded that the technique
anaesthetic and that she had no new health reassured Mrs B and then re-sedated her for used by Dr S was very poor given the
problems. Dr S reassured Mrs B that it approximately 40 minutes. Following that she complications that followed.
should be a routine procedure and that he was woken again and her airway was removed.
anticipated no problems. He warned her Weakness of all four limbs was still noted. 4. D
r M was critical of the levels chosen by
about the possibility of dental damage and Dr S to perform the block. He felt that C7
sore throat and promised that he would Over the next five hours Mrs B regained was too high, given that the dermatomal
not use her left arm for IV access or blood normal sensation and power in her lower level of the surgery was approximately
pressure readings, because of the previous limbs and left arm. However, her right T4. He also felt that the surgery was
lymph node dissection on that side. arm remained weak, with an absence of very minor and did not warrant the
voluntary hand movements. She also had paravertebral block. Dr M was of the
In the anaesthetic room, Dr S reviewed the gait ataxia on attempting to mobilise. An opinion that infiltration of local anaesthetic
anaesthetic chart for Mrs B’s mastectomy MRI was performed the following day, which by the surgeon, combined with simple
procedure. He saw that Mrs B had demonstrated signal change and subdural analgesics, would have sufficed.
received a general anaesthetic along with haemorrhage in the spinal cord at a level
a paravertebral block for post-operative consistent with her persistent symptoms. On the basis of the expert evidence Medical
analgesia, and this technique appeared Protection concluded that there was no
to have worked well. He did not, however, Mrs B remained in hospital for physiotherapy reasonable prospect of defending the
discuss this with Mrs B. and rehabilitation. Her walking and right hand claim. The case was eventually settled
function gradually improved and she was for a substantial sum.
Dr S inserted a cannula in Mrs B’s right arm discharged three weeks after her operation.
and induced anaesthesia with fentanyl Six months later, Dr S received a solicitor’s
and propofol. He inserted a laryngeal mask letter stating that Mrs B was still having Learning points
airway and anaesthesia was maintained with problems with her hand and was seeking be
1. Local anaesthetic blocks should only
sevoflurane in an air/oxygen mixture. Mrs compensation. tion.
performed when there is a clear indica
B was then turned on to her side and Dr S ld
2. The risks and benefits of the block shou
proceeded to insert left-sided paravertebral EXPERT OPINION be discussed with the patient and clear ly
blocks at C7 and T6. Although Dr S used a Medical Protection instructed Dr M, a
documented. The process of consent
stimulating needle and a current of 3mA, he consultant anaesthetist, to comment on the for any operation should be a detailed
nt
had difficulty eliciting a motor response at standard of care. Dr M was critical of Dr S conversation between clinician and patie
either level. At T6, Dr S finally saw intercostal for four major reasons: evidence. The incide nce
with documented
muscle twitching after a number of needle and potential impact of any common and
ld
passes. Twitches were still just visible when 1. Dr S had failed to inform Mrs B that he potentially serious complications shou
the current was reduced to 0.5mA and Dr S intended to perform a paravertebral block always be discussed and documented.
therefore slowly injected 10ml of Bupivicaine and failed to discuss the risks and benefits 3. Local anaesthetic blocks should only
0.375% with clonidine. At the upper level, of such a technique. be performed by practitioners with
Dr S could not elicit a motor response despite appropriate training and expertise.
r
several needle passes. He eventually decided 2. H
e was somewhat critical of the 4. If difficulties are encountered, eithe
to use a landmark technique and injected the decision to perform the block with Mrs the procedure should be abandoned or
same volume of local anaesthetic mixture B anaesthetised. He opined that had assistance summoned.
at approximately 1cm below the transverse Mrs B been conscious or lightly sedated,
process. she would have alerted Dr S when the JPA
CASEBOOK | VOLUME 24 ISSUE 1 | MAY 2016 | medicalprotection.org 13CASE REPORTS
FAILURE TO FOLLOW
© Wavebreakmedia Ltd/Lightwavemedia/thinkstockphotos.co.uk
SPECIALIST
ADVICE
SPECIALTY GENERAL PRACTICE/NEUROLOGY
THEME PRESCRIBING
SUBSTANTIAL
F
ollowing a hospital admission
for status epilepticus, which
was attributed to a previous
cerebral insult, Mr G, a 35-year-old clerical field defect on a routine examination. The EXPERT OPINION
officer, was started on an anticonvulsant ophthalmic surgeon, Mr D, noted that Mr G Medical Protection’s GP expert was critical of
regime of phenytoin and sodium valproate. had been on vigabatrin for in excess of 11 Dr L’s failure to act on the neurologist’s advice
Over the next few years, the medication years during which time he had not been to tail off the vigabatrin and for the absence
was changed by the hospital several times in monitored. His visual fields were noted to be of any record that Dr L monitored the patient
response to the patient’s concerns that his markedly constricted, which was attributed or reviewed his medication. Dr L’s decision
epilepsy was getting worse. After a further to the vigabatrin. Mr G was referred to to refer Mr G to an epilepsy specialist once
seizure led to hospital admission, the patient another neurologist who recommended a he was alerted to the potential side effects
was discharged on vigabatrin on the advice of change of anticonvulsant. Mr G was was appropriate and Dr L could not be held
the treating neurologist, Dr W. Readmission gradually weaned off the vigabatrin. accountable for Mr G’s failure to attend a
for presumed status epilepticus a short while number of hospital appointments, which may
later led the hospital to conclude that there As a result of the damage to his eyesight, have contributed to the delay in diagnosing
might be a functional element to the seizures. Mr G brought a claim against the hospital the visual field defect. The claim was settled
This was supported by psychiatric evaluation. for negligent prescription of vigabatrin and on behalf of Dr L and the Trust for a reduced
The patient was discharged to psychology failure to warn the claimant of the side but still substantial sum.
follow-up with a recommendation at the effects. Mr G also brought a claim against
end of the discharge summary to gradually Dr L for continuing to prescribe vigabatrin
tail off and stop the vigabatrin. This advice against the advice of the neurologist, failing
was overlooked by Mr G’s GP, Dr L, who to review the medication at regular intervals,
continued to prescribe as before. The error and failing to refer to an ophthalmologist.
was not picked up by either Dr L or the
hospital despite multiple contacts and
several hospital admissions over the next five
years, for the first three years of which Mr G
remained under the care of Dr W. Learning points
if it is
they take responsibility for it – even
Subsequently, Mr G was seen by both Dr L • If a doctor signs a prescription, on betw een prim ary and
com mun icati
and his optician, complaining of tired, heavy on the advice of a specialist. Good appropriate treatment.
to ensu re patie nts rece ive the
secondar y care is vital ssets/
eyes. No visual field check was carried prescribing practice: mcnz.org.nz/a
See the MCNZ statement on Good -pra ctice.pdf.
out on either occasion. Nine months later nts/Good-prescribing
News-and-Publications/Stateme
Mr G returned to see Dr L, requesting a e is a need for monitoring or regular
referral to the epilepsy clinic as he had read • Patients should be informed if ther
ications. Whe re there is shared care with
review of long-term med te
a newspaper report about the visual side ld be sought as to the most appropria
another clinician, agreement shou clear ly documented.
effects of vigabatrin. An appointment was itoring. All advi ce shou ld be
arrangements for mon
made at the clinic but Mr G failed to attend us side effect of medication, prom
pt
on two occasions. An urgent referral was • When alerted to a potentially serio spec ialist if appropriate.
shou ld be mad e, with a
arrangements for review
ultimately made by Mr G’s optician several
months later following detection of a visual
JP
14CASE REPORTS
UNDESCENDED
TESTIS
SPECIALTY GENERAL PRACTICE
THEME SUCCESSFUL DEFENCE
© mauro fermariello/science photo library/sciencephoto.com
EXPERT OPINION
B
aby LM was taken to see his GP, Dr E, for his
six-week check. During this examination Dr E Medical Protection obtained expert opinions from a GP and a
noted that his left testis was in the scrotum but consultant in paediatric surgery. Both were supportive of Dr E’s
his right testis was palpable in the canal. He asked LM’s examination and management. The consultant in paediatric surgery
mother to bring him back for review in a month. thought that LM had an ascending testis. This is a testis which is
either normally situated in the scrotum or is found to be retractile
Two weeks later his mother brought him to see Dr during infancy, and later ascends. He thought that even if LM had
E because he had been more colicky and had been been referred in infancy, it would have been likely that examination
screaming a lot in the night. As part of that consultation, would have found the testes to be either normal or retractile and
Dr E documented that both testes were in the scrotum. he would have been discharged with reassurance. He explained
that it is thought that in cases of ascending testis testicular ascent
LM was brought for his planned review with Dr E in occurs around the age of five years. Therefore, on the balance of
another two weeks. Both testes were noted to be in the probabilities, referral to paediatrics before the age of four would not
scrotum although this time the left testis was noted to be have led to diagnosis of an undescended testis.
slightly higher than the right. His mother was reassured.
This claim was dropped after Medical Protection issued a
When LM was 16-months-old he appeared to be in some letter of response to the claimant’s legal team which
discomfort in the groin when climbing stairs. His mother carefully explained the expert opinion.
was worried so she took him back to Dr E for a check-up.
Dr E examined him carefully and documented that both
testes felt normal and were palpated in the descended
position. He also noted the absence of herniae on both Learning points
sides. He advised some paracetamol and advised his te
defend Dr E in light of his appropria
mother to bring him back if he did not improve. • Medical Protection were able to expe rt advi ce.
ping and the
clinical management, good note-kee
ed Dr E’s defe nce. Doctors should always
When LM was 15-years-old he noticed that one of his • Good documentation help
of both testes in the scrotum at
testicles felt different to the other. At that time he was document the presence or absence
found to have a left undescended testis which was the six-week check.
cy
excised during surgical exploration. ally situated in the scrotum in infan
• A testis that is retractile or norm ul leafl et for parents
in the UK has a usef
can ascend later. NHS Choices
in young boys aren’t a cause for
LM’s mother felt that Dr E had missed signs of his outlining that “retractile testicles
cles often settle permanently in the
undescended testis when he was younger. A claim was concern, as the affected testi
, they may need to be monitored
brought against Dr E, alleging that he had failed to carry scrotum as they get older. However
som etimes don’t descend naturally and
out adequate examinations and that she should have during childhood, because they
treatment may be required” .
1
referred to the paediatric team earlier. It was claimed UK
and Care Excellence (NICE) in the
that if Dr E had referred to paediatrics earlier then this • The National Institute for Health cove rs the prim ary
e Summary that
would have resulted in a left orchidopexy, placing the have published a Clinical Knowledg ded teste s,
and bilat eral unde scen
testis normally in the scrotum before the age of two care management of unilateral
: cks.nice.org.uk/undescended-
years and thus avoiding removal of the testis. including referral. It can be found here
testes.
REFERENCES
dedte sticles/Pages/Introduction.aspx
1. nhs.uk/conditions/undescen
AF CASEBOOK | VOLUME 24 ISSUE 1 | MAY 2016 | medicalprotection.org 15CASE REPORTS
DIAGNOSING
PNEUMONIA
OUT OF HOURS
SPECIALTY GENERAL PRACTICE
THEME SUCCESSFUL DEFENCE
M
r B was a 31-year-old man him an appointment at the out-of-hours attempted but sadly failed. A post mortem
with three children. His mother centre, which he declined, but he did agree was performed, giving the cause of death as
was staying with him over the to ring back if he was worse. She “right-sided lobar pneumonia and bilateral
weekend because he was in bed coughing documented that her advice had been pleural effusions”.
and shivering. On Saturday he complained accepted and understood.
of chest pains so his mother rang an Mr B’s mother was distraught and brought a
ambulance. The paramedic recorded Mr B was no better on Sunday so his claim against the out-of-hours GP, Dr Z. She
a temperature of 39 degrees, oxygen mother rang the out-of-hours centre again. claimed that her son had been extremely
saturations of 94%, pulse 134, respiratory This time a nurse spoke to Mr B and noted short of breath on the telephone and that
rate of 16 and a blood pressure of 120/75. his history of productive cough, fever and she had not paid adequate attention to this.
An ECG was done and noted to be normal. aching chest pain. She documented that he She was upset that Dr Z had not arranged
The paramedic explained to Mr B that he had some difficulty in breathing on exertion to visit her son at home and had incorrectly
should be taken to hospital. Mr B declined but that he could speak in sentences over diagnosed a simple chest infection.
and was considered to have capacity so the the telephone. Again she offered him an
ambulance left. appointment at the out-of-hours centre but EXPERT OPINION
he refused, saying he would prefer to see Medical Protection obtained expert opinions
The ambulance crew called their control his own GP on Monday. from a GP and a respiratory specialist. The
centre who in turn contacted an out-of- GP was supportive of Dr Z. He noted that
hours GP, Dr Z. The control centre left a Three days later Dr B’s mother took cough, fever and malaise are very common
verbal message for Dr Z, explaining the him to see his own GP. He found coarse symptoms in a young adult. He listened to
situation, but did not hand over details crepitations in his right upper and mid the recorded consultation and considered
of Mr B’s vital signs including his oxygen chest but with good air entry. He noted Mr B to have been only mildly short of breath
saturations and pulse rate. that Mr B was not unduly distressed and and showing no verbal signs of delirium. He
had no shortness of breath so opted felt it was reasonable for Dr Z to suggest
Dr Z rang Mr B and noted his history of for oral antibiotics and a review in attendance at the primary care centre. He
chest pain triggered by coughing and the two days. also noted that if Mr B had been well enough
normal ECG. She noted his temperature of to attend his own GP four days later, then he
39 degrees and that he had taken some Later the same day Mr B’s breathing could probably have travelled to see Dr Z on
ibuprofen to help. She documented “no became rasping and very laboured. He the day she spoke to him. He felt it had been
shortness of breath” and advised some collapsed and an ambulance took him to neither possible nor necessary to define the
cough linctus and paracetamol. She offered A+E. Cardiopulmonary resuscitation was diagnosis beyond a respiratory tract infection
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