Complaint
The Commissioner received a complaint from the first complainant (one of the consumer's daughters) about the services provided to her late father, the consumer, by the general practitioner. The complaint is that:
- The general practitioner did not respond to the consumer's deteriorating health or abnormal blood test results during a six-month period prior to his admission to a public hospital in late October 1996.
- The general practitioner did not provide information or assistance to the consumer which addressed his decreasing mobility. There was no referral to a physiotherapist or to Disability Support Services.
- The general practitioner did not communicate test results to the consumer as requested.
- The consumer's family had to continually follow up requests for test results.
Investigation
The complaint was received by the Commissioner on 10 November 1997 and the matter was referred to advocacy for the purpose of reaching a satisfactory agreement between the parties. However, the complainant and her family declined this advocacy assistance. An investigation was then undertaken. Information was obtained from the following people:
The Second Complainant / Wife of the Consumer
The First Complainant / the Consumer's Daughter
The Third Complainant / the Consumer's Second Daughter
The General Practitioner / Provider
The general practitioner's medical notes for the consumer were obtained.
Independent advice was also sought from a general practitioner.
Information Gathered During Investigation
Between June and July 1994, the general practitioner treated the consumer for respiratory problems and high blood pressure. At that time, the consumer's blood tests were normal and the general practitioner noted that there was no evidence of heart failure. The consumer was commenced on a respolin autohaler for his respiratory problems and medication for his high blood pressure. The consumer's blood pressure eventually settled, and after May 1996 was found to be hormonal.
By the end of July 1994 the consumer's respiratory condition no longer responded to medication and the general practitioner referred him to the Respiratory Clinic at the second public hospital. The general practitioner commenced the consumer on medication and his condition remained stable through 1995. The consumer continued to attend the respiratory clinic until 1996.
In early September 1995 a respiratory physician at the second public hospital, recorded that the consumer possibly had some heart failure and arranged for tests. The tests indicated bronchitis, asthma and cough syncope with no evidence of heart failure.
In February 1996 a second respiratory physician at the second hospital, met the consumer for the first time. The second respiratory physician noted that the consumer had had a recurrent persistent cough for the last eighteen months, except when on prednisone. The second respiratory physician also recorded that the consumer had paroxysmal sneezing at times (sudden violent attacks of sneezing), but no other respiratory tract symptoms or dyspepsia (indigestion). The second respiratory physician diagnosed the consumer's respiratory distress as asthma and prescribed medication.
In late March 1996, the second respiratory physician noted that the consumer's cough had settled completely with the new medication but that this medication was causing persistent nausea. The second respiratory physician also pointed out that the consumer's latest blood tests had a high eosinophil (a variety of white blood cell) count which could not be explained.
In early April 1996 the second respiratory physician noted that the consumer was still suffering from nausea and the medication was discontinued. Despite different medication being prescribed and discontinued the side effects continued. The second respiratory physician wrote to the general practitioner in mid-May 1996 suggesting that asymptomatic reflux could be triggering the consumer's recurrent coughing episodes and questioning whether it might be possible that his current ongoing nausea, abdominal bloating and anorexia could be from an upper gastro-intestinal problem. At this time the second respiratory physician noted that the consumer's blood test results showed profound eosinophilia. The second respiratory physician ordered further blood tests, gastroscopy, chest x-ray, abdominal ultrasound and urine and faeces tests. The results of these tests, all of which were essentially normal, were sent to the general practitioner. In late May 1996 the general practitioner saw the consumer. The consumer had his blood pressure taken and was told that his blood tests were okay. He only had one problem with an allergy.
However, the consumer's symptoms would not settle and more medication was prescribed. In late June 1996, the general practitioner diagnosed severe congestive heart failure. The general practitioner noted that the consumer had not taken his prescribed frusemide medication for two weeks and the consumer recommenced this medication, after which his condition improved. The family were told that the consumer needed this medication because of fluid on his lungs. The family did not realise that fluid on the lungs was related to congestive heart failure and were unaware that the consumer had any problems with his heart at all.
The general practitioner informed the Commissioner that in June 1996 the consumer's weight was recorded at 78kg. The general practitioner also recorded in her medical notes that in early June 1996 the consumer had problems with his legs, with pains in his calves and behind his knees on walking. The general practitioner attributed this to retention of fluid. The family advised the Commissioner that they believed that the general practitioner was "aware that [the consumer] had leg pains as far back as May 1996 and she suspected that he may have had some clots at that time". These problems had cleared by the end of June. At this time the consumer was also seen by a gastroenterologist at the second hospital. However, the family was becoming increasingly anxious about the consumer's state of health and made many telephone calls to the general practitioner for test results and appointments for further investigations.
In July 1996 the consumer saw a third respiratory physician at the second hospital. The third respiratory physician noted that the consumer had abdominal pain and discomfort and recorded that the consumer had lost two stone in weight. The third respiratory physician wrote to the general practitioner in mid-July 1996 suggesting that, although it was possible that the cause of the illness was Churg-Strauss syndrome, the consumer's chest was better now. The third respiratory physician recorded that the consumer's principal problem was gastritis and that if he did not respond to the medication, the third respiratory physician would refer him to a gastroenterologist. The third respiratory physician also noted that the consumer's persistent eosinophilia in his blood tests could be due to some new collagen vascular disease and polyarteritis nodosa (patchy inflammation of the walls of the arteries) was also a possibility.
The general practitioner referred the consumer back to a gastroenterologist. The gastroenterologist, in his letter to the general practitioner of late July 1996, suggested a colonoscopy and if that was not helpful, a haematological opinion.
During July 1996, the family informed the Commissioner that the consumer continued to lose weight, was not eating and had difficulty walking, complaining of aching legs and joints. The family also told the Commissioner that when the consumer saw the gastroenterologist in mid-August 1996, he was in a wheelchair and was unable to walk. The family, alarmed by his condition and frustrated by the lack of a diagnosis, continued to telephone the general practitioner frequently. The general practitioner saw the consumer and his wife six times in July. According to the family, in mid-July 1996 they were informed by the general practitioner that the consumer had nothing wrong with him and that all the test results were good. The general practitioner discussed the consumer with the gastroenterologist who suggested a different medication, but this also proved unsuccessful. In late July 1996 the family spoke with the gastroenterologist who told them that the consumer's white cell count was rising. However, the family informed the Commissioner that when they telephoned the general practitioner two days earlier to enquire about the blood test results, she had advised that everything was okay.
The gastroenterologist saw the consumer in July, August and September 1996 at the second hospital. The results of the colonscopy report in August 1996 and small bowel study in September 1996 failed to explain his abdominal symptoms. The colonscopy report suggested a possible cause of illness as Crohn's disease (a condition in which segments of the alimentary tract become inflamed, thickened and ulcerated). The gastroeneterologist passed all of these results to the general practitioner. The general practitioner informed the Commissioner that by September the consumer's weight had dropped to 65kg, making a total loss of 13kg in four months.
By this time, the consumer was finding it increasingly difficult to walk, but the general practitioner did not make a note of this in the records or refer the consumer for physiotherapy. The family pointed out to the Commissioner that the general practitioner never visited the consumer and his wife in their home as they had both always attended the surgery. The consumer's wife arranged for a physiotherapist to come and treat the consumer herself. She also arranged for equipment to aid the consumer in bathing and walking. According to the family the general practitioner offered no support or assistance at all. The general practitioner advised the Commissioner that she was unaware that the consumer needed a wheelchair and his decreasing mobility was not brought to her attention.
TBy mid-October 1996 the family noted that the consumer had lost even more weight. It was at this time that the family was told that the consumer's blood tests were "up the shoot". In mid-October 1996, the gastroenterologist suggested to the general practitioner that the consumer might have polyarteritis nodosa. The gastroenterologist ordered other tests and concluded:
"I will be reviewing him in three weeks time in this clinic. Depending upon the outcome of the blood studies today and the symptomatic response to Zoton, there may be a place here for me to admit him to hospital for further investigations which would involve amongst other things, angiography in view of the possible diagnosis here of poly arteritis nodosa. Clearly should he deteriorate in any way between now and [early] November, I would be grateful if you could admit him to [the first public] Hospital to the team on intake."
The consumer's condition worsened. At 2.00pm in late October 1996 his family rang the general practitioner to insist that she admit the consumer to hospital. The general practitioner was not available so they rang again at 5.00pm and according to the family, the general practitioner was quite short with them. The general practitioner admitted the consumer to the first hospital where he died in mid-November 1996.
Advice to Commissioner
The Commissioner obtained advice from a general practitioner in relation to the general practitioner's conduct. The Commissioner was advised:
1. With [the consumer] seeing several different specialists at different hospitals and a general practitioner, I think it is not totally inappropriate that the patient or the patient's family takes some responsibility for ringing up for results.
2. Physiotherapy and home help is often a need that needs to be expressed by the family who are much more aware of the domestic situation. If the difficulties were not made clear to the general practitioner then it is inappropriate to blame the general practitioner for not arranging them.
3. It appears as though [the general practitioner] was available to see [the consumer] on a regular basis and that she appeared to refer appropriately to specialists in order to assist in trying to find a diagnosis.
4. Polyarteris nodosa is a rare condition that requires specialist investigation for diagnosis. It is a condition that is seen extremely rarely in general practice and I would not expect general practitioners to have any experience in diagnosing or managing this condition.
The Code of Health and Disability Services Consumers' Rights
RIGHT 4
Right to Services of an Appropriate Standard
2) Every consumer has the right to have services provided that comply with legal, professional, ethical, and other relevant standards.
5) Every consumer has the right to co-operation among providers to ensure quality and continuity of services.
RIGHT 6
Right to be Fully Informed
1) Every consumer has the right to the information that a reasonable consumer, in that consumer's circumstances, would expect to receive, including -
f) The results of tests
Opinion: Breach
In my opinion, the general practitioner breached Right 6(1) of the Code of Health and Disability Services Consumers' Rights.
Providers have a responsibility under Right 6(1) to keep the consumer fully informed of the results of tests and procedures. In my opinion, the general practitioner failed to fully inform the consumer of his changing blood picture and therefore breached Right 6(1)(f) of the Code of Rights.
The family did not learn of the consumer's abnormal blood results until just before he was admitted to hospital in mid-October 1996. The report of the blood test results in mid-July 1996 showed his blood picture was changing but the general practitioner told the consumer and his family on two subsequent dates that all his tests were normal. This was not accurate. The family required further explanation and frequently rang the surgery but were given inaccurate information.
The general practitioner was the consumer's general practitioner and primary health professional. In this role she was the person seeing the consumer most often and the person who received information from all specialists. Therefore, the general practitioner had a responsibility to keep the consumer fully informed about all test results. In my opinion, she failed to do this and this failure to provide correct, appropriate and timely information was a breach of the consumer's right to be fully informed.
Opinion: No Breach
In my opinion, the general practitioner did not breach Right 4(2) and Right 4(5) of the Code of Health and Disability Services Consumers' Rights as follows:
Right 4(2)
The general practitioner was unable to diagnose the cause of the consumer's deteriorating health. However, she referred him to respiratory and gastrointestinal specialists, and followed the treatment plans suggested by these specialists as appropriate. The specialists considered the consumer's illness had a gastrointestinal cause and the general practitioner was guided by these specialists. Polyarteritis nodosa is a rare condition and is seen extremely rarely in general practice. In my opinion, the general practitioner's actions met the professional standard and therefore did not breach Right 4(2) of the Code of Rights.
The general practitioner was never called to attend the consumer in his home and he always walked into the surgery. The consumer did have pains in his legs, which the general practitioner attributed to fluid retention. The general practitioner treated this, and to her knowledge, the consumer's mobility no longer presented a problem. The general practitioner did not refer the consumer for physiotherapy because this is not the treatment of choice for asthma and abdominal problems. In the absence of information provided about the consumer's disability, the general practitioner could not be expected to refer the consumer to Disability Support Services.
Right 4(5)
The general practitioner was responsible for co-ordinating referrals to various medical specialists. The family's records showed that the consumer had constant access to specialist investigation and consultation in an effort to find the cause of his illness. The family made frequent telephone calls to the general practitioner's surgery for information and the consumer's medical records contain letters, test results and investigation reports of the various specialists. In my opinion, the general practitioner did not breach Right 4(5) of the Code of Rights.
Actions:
I recommend that the general practitioner apologise in writing to the family for breaching the Code of Rights. This apology is to be sent to the Commissioner who will forward it to the family.
Other Actions:
A copy of this opinion will be sent to the Medical Council of New Zealand.
For further information, contact: HDC Communications Section (09) 373 1060.
Or by email: your.rights@xtra.co.nz