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Rural house calls for patient with fractured ribs following fall (00HDC07631)

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(00HDC07631, 19 November 2002)

General practitioner ~ Rural house calls ~ Examination and assessment following fall ~ Missed diagnosis ~ Pain management ~ Patient responsibility ~ Rights 4(1), 4(4)

A complaint was made by a woman about the care provided to her husband following a fall. The GP made three house calls to the 69-year-old patient in the country. The complaint was that the GP did not adequately examine the patient, did not arrange for him to be transported by ambulance for X-rays, even though he was in too much pain to move, and did not diagnose the injuries sustained by the patient in his fall.

When the GP subsequently referred the patient to hospital, he was diagnosed with fractured ribs and a sub-acute bowel obstruction (paralytic ileus). It later became apparent that the morphine and laxative the GP had prescribed were not administered in accordance with his instructions.

The Commissioner held that the GP did not breach Right 4(1), as there was no complication evident during the examination, so his clinical decision not to refer the patient for X-rays was correct and appropriate. X-rays for fractured ribs are not necessary in the absence of complications.

The head and neurological examinations undertaken were thorough and the GP gave good advice about concussion. The patient's chest was examined and the findings appropriately documented. The advisor considered it unlikely that the complications of bowel obstruction (an acknowledged but relatively rare risk of rib fractures) and lung collapse were clinically evident, as both conditions take time to develop. Therefore the GP did not breach Right 4(1), as his initial examination was adequate in the circumstances and consistent with the patient's needs.

With regard to the complaint that the GP did not correctly diagnose the patient's injuries from the fall, the GP's initial diagnosis was appropriate in that he considered concussion and diagnosed fractured ribs. The advisor commented that if the GP had adopted a patient-centred method of assessment, he would have noted that the patient's level of functionality was not improving, and this should have triggered either an earlier admission to hospital or closer follow-up. However, the GP did not breach Right 4(4), as he could not be criticised for the adequacy of his management when his treatment plan regarding pain relief and bowel management were not adhered to. The Commissioner commented that patients and/or their caregivers have a responsibility to ensure medications are taken as prescribed.