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Surgical emergency missed by locum casualty officer and overworked surgeon (02HDC08734)

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(02HDC08734, 26 September 2003)

Public hospital ~ Casualty officer ~ General surgeon ~ Emergency Department ~ Missed diagnosis of testicular torsion ~ Consultant responsibility ~ Resource constraints ~ Right 4(1)

A woman complained about the services provided to her 12-year-old son at the Emergency Department of a public hospital. The complaint was that the general surgeon and the casualty officer failed to:

1) properly assess the patient to determine the nature of the injury to his scrotum;
2) admit the patient to hospital for immediate exploratory surgery; and
3) diagnose the patient with testicular torsion, with the result that his right testicle had to be surgically removed.

The Commissioner reasoned that the locum casualty officer, who was an internal medicine specialist, could not reasonably have been expected to recognise that the patient's injury required urgent surgery, so her assessment and diagnosis was reasonable in the circumstances. A telephone call from the casualty officer to a specialist surgeon carried with it a transfer of responsibility. The casualty officer was not required to fully impress her concerns, or specifically seek the specialist's attendance or plead for assistance. When the casualty officer conveyed the injury, condition, and her management plan, responsibility for the patient's care passed to the on-call consultant. Therefore, the casualty officer did not breach the Code because she acted appropriately when she sought consultant advice.

With regard to the general surgeon, it is a defence for any clinician to prove that he or she acted reasonably in the circumstances (clause 3 of the Code). Resource constraints are highly relevant circumstances in a small, provincial hospital. The surgeon provided a wide range of surgical services with no senior support. The surgeon did not breach Right 4(1) because it would be unduly harsh to single him out as responsible for the misdiagnosis of the patient's condition. There were extenuating circumstances in this case, in that:

1) he was affected by resource constraints;
2) his own heavy workload, and in particular the large amount of information from a variety of disciplines that he was required to assess each day, no doubt significantly increased the risk of an error;
3) his failure to appreciate that the casualty officer was seeking his advice was genuine, albeit mistaken; and
4) testicular torsion in a 12-year-old boy (who had suffered a trauma but was responding well to medication) was very unlikely.