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Care and treatment of a woman with ongoing bowel symptoms (10HDC00974)

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(10HDC00974, 15 June 2012)

General practitioner ~ Medical centre ~ Rectal bleeding ~ Diarrhoea ~ Bowel cancer ~ Examination ~ Diagnosis ~ Referral ~ Systems ~ Multiple providers ~ Continuity of care ~ Documentation ~ Rights 4(1), 4(2)

A 62-year-old woman complained about the care provided to her by her general practitioner (GP) over a period of nine months.

The woman consulted her GP complaining of rectal bleeding and discomfort. The GP prescribed the woman Ultraproct cream, but did not physically examine her. The documentation from this consultation is very limited, with no reference to the reason for the consultation, the woman's symptoms, the clinical findings or the diagnosis.

Three months later the woman returned to the GP, who prescribed a repeat of the Ultraproct cream. Again the notes are very limited, with no reference to bowel symptoms or any other indication why the Ultraproct had been prescribed. The GP did not physically examine the woman at this consultation.

Five months later, the woman consulted the GP again. There is nothing documented in the clinical notes about the consultation, other than "see [referral] letter". This was a letter referring the woman to the public hospital for a colonoscopy to "exclude pathology". The GP noted in her referral letter that the woman had had diarrhoea for the past year and had lost five kilograms in the last four months. The GP forgot to print the referral letter and it was never sent.

Five weeks later, the woman went to the public hospital after experiencing severe bowel pain. She was subsequently diagnosed with bowel cancer.

The GP was held to have breached Right 4(1) for failing to examine the woman's abdomen and rectum at two of the consultations. The GP breached Right 4(1) for failing to send the referral letter to the public hospital and failing to have in place an adequate system to alert her to instances where referrals had not been actioned as intended. The GP also breached Right 4(2) of the Code for failing to meet professional standards in terms of her documentation.

The medical centre where the GP practised did not breach the Code, but adverse comment was made in relation to its systems for following up specialist referrals, and for repeatedly failing to inform the woman that her usual GP would not be present at appointments which had been booked with her usual GP.

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