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Missed diagnosis of ulcerative colitis in young mother presenting with rectal bleeding (00HDC08356)

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(00HDC08356, 14 August 2002)

General practitioner ~ Standard of care ~ Clinical examination and investigations ~ Missed diagnosis of ulcerative colitis ~ Record-keeping ~ Rights 4(1), 4(2)

A 24-year-old woman complained that her GP did not properly investigate her symptoms, despite repeat consultations and her worsening condition, and did not recognise that she was dehydrated or take steps to hospitalise her.

The woman, who was six weeks postpartum and had a past history of haemorrhoids and postnatal depression, presented with rectal bleeding. The GP's initial diagnosis was haemorrhoids and later a viral gastronenteritis. There was no clinical examination of the rectum with a proctoscope. The GP referred her to an outpatient clinic. At the time of the patient's admission to hospital she was significantly dehydrated. She was diagnosed with ulcerative colitis and underwent a total colectomy and ileostomy.

The Commissioner held that the GP breached Right 4(1) by failing to perform a rectal examination in a patient complaining of haemorrhoids and rectal bleeding, even though a rectal examination is not usually helpful in diagnosing ulcerative colitis, and earlier diagnosis and/or treatment may well have had no material effect on subsequent events or avoided the need for major surgery.

It was noted that a patient with severe diarrhoea can progress from mild to moderate to severe dehydration over a period of eight hours, and that while significant dehydration had developed by the time of hospital admission, the patient was not so obviously dehydrated during the consultation as to require immediate hospitalisation. However, the GP breached Right 4(1) by failing to examine the patient sufficiently to decide whether she was dehydrated.

The GP also breached Right 4(2) by failing to keep adequate records. The clinical records were below RNZCGP standards, particularly in respect of legibility, clear recording of history, assessment, problem list, and management plan. It was noted that patients who attend an Accident and Medical Clinic may not always see their doctor of choice, and it is therefore essential that notes of previous consultations are legible, complete, and sufficiently detailed to allow the treating doctor to know the medical history.