Names have been removed (except the expert who advised on this case) to protect privacy. Identifying letters are assigned in alphabetical order and bear no relationship to the person's actual name.
General Practitioners
Complaint
On 12 June 1997 the Commissioner received a complaint from a consumer about services provided to him by two General Practitioners. The consumer's complaint was that:
- The first GP prescribed painkillers for the consumer for severe back pain one day in mid-August 1996 and inappropriately prescribed painkillers again for the pain three days later without a further physical review.
- The second GP attended the consumer on the evening of the following day and after a cursory examination (which did not include any neurological test or the taking of a temperature) administered morphine and phenergan.
Investigation
An investigation was commenced and information obtained from:
The Consumer
The first General Practitioner/Provider
The second General Practitioner/Provider
The Team Leader, Physiotherapy group
The consumer's Housekeeper
The consumer's Support person, a Registered Nurse
Medical records were obtained from the Crown Health Enterprise and viewed as part of the investigation. The consumer supplied a copy of the first GP's medical records for the period concerned. These were included in the investigation.
The Commissioner sought advice from an independent General Practitioner.
Outcome of Investigation
The first GP
One day in mid-August 1996 the consumer placed a telephone call to the first GP's surgery explaining that he was suffering from lower back pain. The consumer requested that the first GP visit him at home, as he was unable to attend her surgery. The first GP was unable to attend the consumer immediately and as an interim measure prescribed Voltaren to assist with the pain. The prescription for Voltaren was delivered by the pharmacy before midday and the consumer immediately took the recommended dose.
The first GP visited the consumer at home at the end of her afternoon surgery and advised "…he met me at the back door, looking somewhat embarrassed, and said he was going to cancel my visit as he felt so much better…" The first GP states that the consumer walked without difficulty and that they sat on ordinary chairs at a dining table while they talked. At the conclusion of this discussion the first GP conducted an examination of the consumer that involved flexion and extension of his spine. The first GP's notes show that flexion at the lumber spine was full, they only moved slowly, extension was normal and that he experienced some back pain on lateral flexion on the right side but none to the left. The first GP considered these findings to be consistent with an almost resolved mechanical back pain.
The consumer advised that at the time of the GP's visit the pain was still present but had subsided considerably due to the Voltaren. At the conclusion of the consultation the GP advised the consumer to continue with the Voltaren, rest and that these things generally cure themselves within a few days. The GP also advised the consumer that it may be necessary for him to have an orthopaedic consultation in the future but no arrangement was made as to how that would be assessed.
The consumer's pain returned and on the Thursday morning (three days later) he asked his housekeeper to contact the first GP and explain the situation. The consumer's Housekeeper advised the Commissioner she informed the GP that she thought the consumer had got worse, stating that he wanted to see her. The GP appeared reluctant to visit the consumer as he had not been very co-operative regarding an examination on the previous visit and had only wanted something to be given there and then for the pain.
The first GP disagrees that a visit was requested and advised that the information she received from the consumer's Housekeeper was that "…the back pain had recurred, [sic] and that more Voltaren was requested. Delivery of this was arranged. I did not say that I was unable to call…I would have made a house call at the end of surgery had it been requested." During an interview the first GP added that during this conversation she was drawing on the information from her visit to the consumer three days before when he had been much improved at the time of the visit. In addition to the further prescription for Voltaren, the GP arranged for a community physiotherapist to visit the consumer that afternoon.
The Team Leader of a Physiotherapy group confirmed she visited the consumer that day and that a full examination was impossible as the consumer's pain was extremely acute. "Tens" treatment was administered as well as instruction on getting in and out of bed and a pair of elbow crutches were also supplied. A second visit was conducted the next day (Friday) and the consumer's pain appeared worse. The Team Leader has advised that "Although I haven't documented it, I seem to recall ringing the GP on the day reporting the deterioration on [that day], I had felt that he had a disc prolapse, but on the [day of the second visit] I was uncertain of the probable cause of his pain."
The first GP advised that "…from memory I didn't receive any information back from the physio by which I assumed all was OK."
From 5.00pm on the Friday until 8.00am on the Monday the first GP's practice was covered by an After Hours Service.
The second GP
On the Friday evening the consumer had a friend visit, who arrived around 5:45pm. The friend/support person is a Registered Nurse. She stated "[the consumer] was in bed. He was not interested in eating and was drinking very little. He was medicating on Voltaren and panadol. He was extremely lethargic, seemed generally unwell and I was very concerned about him."
At 10:30pm when the consumer got out of bed to walk to the toilet, his support person noticed how impaired his movement was and assisted him back to bed.
About an hour later he attempted to go to the toilet again and was not able to do so. He had difficulty explaining to his support person what was happening so she phoned the After Hours Service around 11:50pm and made the consumer comfortable on the floor. The receptionist told the support person that it would be about three-quarters of an hour before a doctor could attend.
The second GP was on another home visit when she was requested to visit the consumer. She caught a taxi immediately at the conclusion of that home visit and went directly to the consumer's house. The second GP arrived just after 1:00am and the consumer's support person gave the doctor an outline of the week's events as she understood them.
The consumer's support person advised that she was concerned that the second GP did not pick up on anything she said and did not ask about the consumer's medical history, and seemed unconcerned that the consumer was having difficulty speaking. The support person stated "She just ran her finger across his lower back, took Morphine and phenergan out of her medical cabinet, asked me to check it, and injected it into him. She then made quite a 'to do' about changing his wet pyjama pants, bed rolling him and splinting him on his side with pillows etc. I collected a urinal from A & E ([the second GP] arranged this by phone). When I got back the doctor had gone. She gave me no indication of what she thought was the matter with [the consumer]".
The second GP's notes record that she found the consumer cast and unable to move on the floor. The second GP advised the Commissioner that the consumer's position was one that people with back pain often adopt. The notes record she took a history and that hospital admission was considered. The second GP advised the Commissioner that as a capable support person was present she decided it was not necessary to arrange admission at that stage. Her notes record: "…Adv re push fluids as dehydrated. Review mane re pain/coping - may need admission." Upon advice that Voltaren had been prescribed the second GP decided to prescribe morphine for pain relief and relaxation and phenergan for relaxation and antiemetic. The second GP then arranged for a urinal from A&E to assist the consumer who would then not be required to get out of bed. The second GP noted that she did not take the consumer's temperature with a thermometer but used her hand to ascertain any fever.
The second GP phoned the next morning at 8:15am prior to going off duty and advised the consumer's support person to get the consumer up, give him Voltaren and call back if she had any trouble. The second GP advised the Commissioner that her phone call before going off duty was to ensure that the consumer had slept and was comfortable and that he and his companion were coping. She stated that she received such reassurance. The consumer's support person commented "Of course none of this was possible. [The consumer] became increasingly confused and drowsy and when I realised that he was totally incontinent at 11:20am I phoned the [After Hours Service] back."
An on call doctor from the After Hours Service arrived and examined the consumer who was admitted by ambulance to Hospital for joint orthopaedic/medical care including treatment for dehydration.
The consumer was diagnosed with an epidural abscess posteriorly situated at LS-S1 and S2 levels. As a consequence of this infection suffered from septicaemia.
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.
Opinion: No Breach, First GP
In my opinion the first GP did not breach Right 4(2) of the Code of Health and Disability Services Consumers' Rights.
When the consumer rang the first GP the first time the surgery was understaffed by one doctor and therefore the GP agreed to visit the consumer at home later in the afternoon. As an interim measure she telephoned a prescription for Voltaren to his usual pharmacy and requested it be delivered. The first GP was aware that the consumer was able to take Voltaren as she had prescribed it to him the year before for a knee problem. The first GP examined the consumer and he did not have severe symptoms of pain at that time. While I accept that the Voltaren may have masked some of the medical problem by the time the first GP visited, in my opinion the actions taken by her were appropriate in the circumstances.
On the Thursday when the consumer's housekeeper rang to request a further supply of Voltaren, the first GP recorded in her notes that the back pain had re-occurred and arranged delivery of further Voltaren. She advised that she would have made a house-call if this had been requested and I accept her response. I also accept that her actions were reasonable in the circumstances. The consumer was a long-term patient of the GP's and she had no reason to believe that his pain had become severe at this stage. The first GP took further action in arranging a physiotherapist who called on the consumer on Thursday and Friday. The first GP did not receive any call from the consumer on the Friday.
In my opinion the first GP took reasonable actions in the circumstances both at her consultation with the consumer on the Monday and her follow-up prescription on the Thursday.
Opinion: No Breach, Second GP
In my opinion the second GP did not breach Right 4(2) of the Code. There is no link between the After Hours Service and patient records with General Practitioners for whom they provide service at weekends. The After Hours Service will have information on a patient if they have attended the person in the past but such information will only be specific to that after hours consultation.
I accept the second GP appropriately obtained history, administered relief, ensured the consumer was comfortable and followed this up with a phone call at 8:15am to check on his status. No warning was given to her at that time that she should reassess the situation. The next phone call to the After Hours Service was made over 10 hours after the second GP's visit and in the particular circumstances the doctor attending on that afternoon had the benefit of more information than the second GP and appropriately admitted the consumer to hospital.
Actions
As a result of this investigation I have some suggestions to make as follows:
- The second GP should reconsider carrying a thermometer with her for after hour visits. While I recognise these can be left behind I think it is an appropriate diagnostic device to hold in her possession.
- The Crown Health Enterprise as employer of physiotherapists should establish formal protocols with general practitioners to ensure appropriate instructions are forwarded to physiotherapists where treatment is required. The protocol must state that when physiotherapists are concerned regarding the patient's symptoms, the physiotherapist will make direct contact with the general practitioner and record the discussions and the notes.
- The After Hours Service should establish procedures to check after hours with general practitioners whose patients use their after hours services. In circumstances where there is some concern regarding patients recently treated by a general practitioner, the emergency doctor could contact the general practitioner to follow up the recent medical history.
A copy of this opinion will be sent to the Crown Health Enterprise and the After Hours Service to ensure they understand the circumstances in which these suggestions are made. A copy has also been sent to the Medical Council of New Zealand.