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Follow-up of referral; appropriate examinations (14HDC00919)
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(14HDC00919, 15 August
General practitioner ~ Medical centre ~ Public hospital ~
District health board ~ Referral ~ Respiratory failure ~ Coronary
artery disease ~ Examinations ~ Communication ~ Follow up ~ Rights
A 38-year-old man began to have coughing fits, particularly at
night. He saw his GP, who thought the man might have an infection
in his chest, and prescribed antibiotics.
A few months later the man returned to his GP because of further
coughing fits, bleeding from the nose, and episodes of shortness of
breath. The GP documented that a specialist assessment was
required. The GP sent a semi-urgent referral to the District Health
Board's (DHB) respiratory service. The referral gave no indication
of the duration and severity of the man's symptoms or the duration
of his smoking history, and no physical findings were included
other than blood pressure.
One night, the man experienced continual coughing for about
eight hours. He returned to his GP the following day and told him
what had happened. The GP ordered a full set of blood tests and
documented that the man needed an urgent respiratory appointment.
The GP told HDC that at this point he sent off a referral to the
DHB for urgent specialist assistance, but there is no evidence of
that referral in the medical notes, and the DHB did not receive
The man returned to the GP a week later. Following that
appointment, the GP sent a new referral to the DHB, this time for
specialist gastroenterology review. The DHB informed the GP that an
appointment had been booked for the man at "the medical clinic".
The GP assumed this appointment was for the specialist respiratory
appointment. In fact, it was for the gastroenterology review. The
DHB subsequently informed the man that he had also been booked in
for respiratory testing on a different date. However, the DHB did
not inform the GP about the respiratory testing.
The man visited his GP again a week after his previous
appointment, but as the GP was already fully booked with other
patients, he did not review the man formally or examine him
physically. However, he did see him and prescribed an
Sadly, the man died the following day. His post-mortem recorded
his cause of death as "respiratory failure due to severe pulmonary
oedema and pleural effusions". He was found to have had severe
coronary artery disease, signs of an old myocardial infarction (a
heart attack), and an enlarged liver.
It was held that the GP failed to advocate appropriately for the
man by failing to follow up the respiratory referral or inform the
DHB when the man's condition deteriorated, and failed to carry out
the appropriate physical assessments of the man before prescribing
an antibiotic. Accordingly, the GP failed to provide services with
reasonable care and skill and breached Right 4(1). There was also
found to be a pattern of inadequate documentation in the GP's
referral letter and clinical notes. Accordingly, the GP breached
Adverse comment was made about the DHB regarding its
communication with the GP.
It was recommended that the GP undertake further education and
training on clinical documentation, and report back to HDC on the
effectiveness of changes he had made to his practice following the
events in question. It was also recommended that the DHB report
back to HDC regarding changes made to its communication system.