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Registrars miss uncommon diagnosis of ischaemic bowel in young woman (01HDC02515)

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(01HDC02515, 30 April 2003)

Public hospital ~ Surgical registrars ~ General surgeon ~ Acute abdominal pain ~ Missed diagnosis of ischaemic bowel ~ Consultant responsibility ~ Resource constraints ~ Right 4(1)

A man complained about the services provided to his 19-year-old daughter by two surgical registrars and a laparoscopic/general surgeon at a public hospital on the basis that: (1) when the patient was transferred to the hospital's Emergency Department suffering severe abdominal pain the surgical registrar did not examine her for two hours; (2) the surgical registrar took abdominal X-rays and incorrectly diagnosed gallstones and ordered an ultrasound for 2pm the following day; and (3) the following day the duty doctor on the ward did not appreciate the seriousness of the patient's condition and treated her inappropriately. The doctor confirmed the previous diagnosis, which was later proven incorrect, and confirmed the need for an ultrasound.

The Commissioner reasoned that a patient presenting to a public hospital with acute abdominal pain should expect a nursing assessment followed by a medical assessment within a reasonable time frame. Nevertheless, the delay in assessment by the first surgical registrar did not breach Right 4(1) because the Emergency Department was short-staffed and he was attending to other acute cases. However, the registrar could and should have arranged for another doctor to assess the patient if he could not respond to the pager calls.

There was no criticism of either registrar for failing to reach a correct diagnosis because ischaemic bowel is unusual and difficult to diagnose. However, both registrars were held to have breached Right 4(1) in failing to obtain timely consultant advice for a patient in severe pain requiring repeated doses of pain relief while the diagnosis remained uncertain.

The laparoscopic/general surgeon did not breach Right 4(1) because he assessed the patient and took her immediately to theatre, and so acted reasonably in the circumstances. It is not practicable for consultants to oversee every decision made by junior doctors, and tasks may be delegated where appropriate. A consultant may reasonably rely on a certain level of competence from junior doctors, and should be able to expect that they will call for assistance or consult when necessary.

The hospital did not breach Right 4(1) because it had adequate systems in place to ensure procedures for discussing cases with consultants were clearly understood and followed by staff.