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Management of thigh injury that progressed to osteomyelitis; communication with Samoan patient with limited English (02HDC04045)

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(02HDC04045, 26 May 2004)

General practitioner ~ Medical centre ~ Standard of care ~ Leg injury ~ Infection ~ Effective communication ~ Rights 4(1), 4(5), 5(1), 6(1)(b)

A 30-year-old Samoan man with limited English injured his right thigh in an area in which he had previously sustained an injury from a rugby tackle. He visited a GP at an accident and medical centre accompanied by a friend, who helped to interpret. The GP was told that the man had injured his leg falling from a tree; he noted that although the man was walking with a slight limp he was able to weight-bear and had a full range of movement. The GP diagnosed a thigh sprain and referred him to a physiotherapist. He prescribed two medications to control pain and inflammation, and explained the dosage and frequency. The man recalled returning to the medical centre a week later because he had run out of pain medication; however, there is no record of this visit, and the medication prescribed by the GP would have lasted longer than one week.

The man returned to the medical centre two weeks later because his health was deteriorating and he felt very unwell; he again took a friend with him, although this friend had very little understanding of English. The practice nurse noted that the man had been unable to attend physiotherapy because of lack of transport. He was examined by a second GP, who found no evidence of systemic problems, and agreed with the first GP's diagnosis; she prescribed more of the same medications and again advised the man to attend physiotherapy. He did so three days later; the physiotherapist noted that only the hamstring was painful and treated that. At a second visit five days later, the physiotherapist noted that the thigh had become very swollen, and told the man to see a GP. He returned to the medical centre later that day, but there was some confusion about payment of his account from the earlier visit, and he left without being seen by a doctor, despite the medical centre's policy of assessing patients regardless of the state of their account.

The man then went to the Emergency Department at a public hospital, again with a friend. The triage notes record that he injured his leg in a rugby tackle, and noted "limited English". The registrar noted that the leg swelling had increased since physiotherapy, with mild pain but no fever. After examination he diagnosed an internal bruise or blood clot in the right quadriceps, which may have been exacerbated by physiotherapy. He advised the man to cease physiotherapy for a week and to return if he had any further concerns.

On visiting his family in another city two days later, the man's mother was shocked at his appearance and insisted on calling an ambulance. At the local public hospital, he was admitted with a diagnosis of sepsis and reviewed by an orthopaedic surgeon, who commenced antibiotics and attempted to aspirate the thigh, with no result. The man's temperature remained high the following day and an urgent MRI scan was carried out, as the surgeon suspected osteomyelitis with septicaemia. The scan showed no abscess, but as the man's clinical state still strongly suggested it, he was taken to theatre and an "extremely large" abscess was located and drained. While in hospital the man suffered acute liver and kidney failure; he has since recovered but has not regained full function in his leg.

The man complained about the standard of care provided at the accident and medical centre and at the first public hospital, and about the communication by the first GP about the dosage of painkillers.

It was held that the first GP was not in breach of the Code. Given the history of the injury (falling from a tree), he adequately assessed the injury, made a reasonable diagnosis, and instituted appropriate treatment, taking reasonable steps to explain his instructions to the man and his friend.

It was also held that the second GP took reasonable steps to investigate the man's symptoms and therefore was not in breach of the Code. Although she could have been more proactive in questioning the first GP's diagnosis and considering other possible causes of the ongoing problems, the diagnosis of thigh sprain remained a reasonable one, especially in the absence of other systemic symptoms, and the treatment and referral to physiotherapy was appropriate.

No further action was taken regarding the services provided at the first public hospital, as the Commissioner was satisfied on the basis of information provided to ACC that the registrar exercised reasonable care and skill in examining and treating the man's leg injury.

However, it was noted that the system at the accident and medical centre of different doctors seeing the man, and the issue with the minor debt problem, did not encourage follow-up of the problem and ensure continuity of care. Further, an error in the man's name as recorded by the first public hospital, brought to light when ACC requested the records, could have had serious consequences if the records were required for future treatment. Accurate records are especially important in situations where patients inevitably see different health providers.

Significant communication problems arose during the man's care. Right 5(1) gives consumers the right to effective communication, including use of a competent interpreter "where necessary and reasonably practicable". It is the responsibility of the provider's employer to ensure that reasonable support is available once the provider has identified the need for an interpreter. Although both doctors at the accident and medical centre were aware of the problems and attempted to adjust their approach accordingly, difficulties remained and appear to have contributed to inaccuracies in the history-taking, making the diagnosis more difficult. The medical centre did not appear to have provided its staff with sufficient guidance on determining whether a competent interpreter was needed. It has since developed its policies in this area. The first public hospital has provided staff with training and information about accessing interpreting services.