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Delay in referral of patient with symptoms suspicious of cauda equina syndrome to specialist services (10HDC00454)
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(10HDC00454, 25 June
General practitioner ~ Medical centre ~ Orthopaedic surgeon
~ Public hospital ~ District health board ~ Emergency department ~
Referral to specialist ~ Cauda Equina syndrome ~ Rights 4(4),
A 29-year-old woman complained about the care provided by her
general practitioner (GP) when she presented with right-sided
sciatic pain and tingling in her right foot for four days. The GP
considered that the woman was suffering from a disc prolapse and
consulted an orthopaedic surgeon at the public hospital, who agreed
with this diagnosis and approved of the GP ordering a CT scan. The
GP referred the woman for a CT scan and to the orthopaedic clinic,
and prescribed pain relief and anti-inflammatory medication.
The next day (a Friday) the woman returned to the GP because her
pain was ongoing and she had developed urinary incontinence. The GP
considered the urinary incontinence to be a "red flag". The GP
tried unsuccessfully to contact the on-call orthopaedic surgeon,
left a telephone message, and faxed a referral for the woman to the
on-call orthopaedic surgeon's private clinic. The GP contacted the
hospital radiologist to bring the woman's CT scan appointment
forward, and instructed the woman to go the hospital emergency
department [ED] over the weekend if she did not hear from the
on-call orthopaedic surgeon or if her symptoms worsened.
Five hours later, the on-call orthopaedic surgeon picked up the
GP's message, which did not include the woman's contact details.
The surgeon went to the ED and the wards to look for a patient with
the symptoms the GP described. No patient of that description
presented to the ED over the weekend.
On Monday, the woman had a CT scan. Meanwhile, the GP's referral
arrived in the mail at the on-call orthopaedic surgeon's clinic.
Enquiries were made and the woman was contacted and asked to
present to the clinic. The orthopaedic surgeon operated on the
woman later that day to decompress the L5/S1 spinal disc. The woman
has a permanent disability as a consequence of her disc
It was held that the GP had a duty to ensure that the woman
received a specialist review when she re-presented on the Friday
afternoon. The GP did not fulfil this duty, did not follow up his
telephone message and fax to the specialist, and did not impress
upon the woman the need for a timely review. By not ensuring that
the woman was reviewed by a specialist in a timely manner, the GP
failed to minimise potential harm to her and breached Right 4(4) of
the Code. The GP also failed to ensure co-operation among providers
to ensure quality and continuity of services and breached Right
4(5) of the Code.
The medical centre was not vicariously or directly liable for
the GP's breaches of the Code.
The on-call orthopaedic surgeon acknowledged that he had been
advised about a patient with a spinal problem who had developed
urinary problems. Although he looked for the patient, he should
have made more attempts to track her down. This failure was an
important link in the chain of events that led to the woman not
receiving the timely specialist care that she needed.
At the time of these events, the DHB did not have a written
protocol for primary care referrals to its hospital ED, and
acknowledged that there was no consistent approach from senior
medical staff working in specialties with respect to the processing
of acute referrals from GPs. Confusion about procedures for GPs to
refer patients to hospital specialist services has the potential to
affect patient care. Primary care centres and district health
boards need to work together to develop clear, unambiguous systems
for referring patients between primary and secondary services in
their respective areas. Both the medical centre and DHB made
changes to improve their systems in this regard.