Names have been removed to protect privacy. Identifying letters are assigned in alphabetical order and bear no relationship to the person's actual name.
Complaint
The Commissioner received a complaint from a consumer about the care she received from the provider, a General Practitioner. The complaint is as follows:
When the consumer reported to the provider in mid-November 1997, complaining of stomach pains that had persisted for several days, the provider did not diagnose that the consumer was suffering from appendicitis. The consumer saw her GP the next day, she was admitted to Hospital and had her perforated appendix removed.
Investigation
The complaint was received by the Commissioner on 27 January 1998, and an investigation undertaken. Information was obtained from the following people:
- The Consumer
- The Provider / General Practitioner
- The Senior Medical Officer, Private Health Care Organisation
- A General Practitioner
- A Surgical Registrar
The consumer's clinical records were obtained and considered. Professional/medical advice was provided to the Commissioner by another general practitioner.
Outcome of Investigation
The consumer reported to a private Medical Centre one afternoon in mid- November 1997. The presenting complaint was recorded as "Stomach Cramps". The consumer saw the provider.
The provider noted a three-day history of non-specific abdominal pain with tenderness in the epigastrium and upper right quadrant. The provider considered the possibility of period pain and ectopic pregnancy but excluded the latter after a negative pregnancy test result. He noted the presence of red and white blood cells in the urine. Since white blood cells in urine are suggestive of urinary tract infection the provider sent a urine sample to a laboratory for organism culture and confirmation. He prescribed Buscopan for pain and advised the consumer to see her general practitioner if her symptoms worsened. Laboratory test results were sent to the consumer's nominated general practitioner. When the provider saw the laboratory result the next day, he rang the consumer's home and was told she was in hospital with appendicitis.
In his response to this complaint which was sent to the Senior Medical Officer of the Private Health Care Organisation in mid-December 1997, the provider wrote: "I told her that I was not quite sure of the cause of her pain as there were no conclusive signs and certainly nothing suggestive of peritonism. I advised her to see her GP if things deteriorated and prescribed Buscopan to see if this eased her pain...Obviously, the diagnosis was missed at the time but in hindsight there were hardly any signs suggestive of acute appendicitis."
The consumer again wrote to the Senior Medical Officer of the Private Health Care Organisation three days later, and set out in detail her recollection of the consultation with the provider. In that letter the consumer said she told the provider she had had stomach pain since the previous Sunday. This pain started round her umbilicus and "moved lower down and to the right". There was also some back pain. She confirmed that the possibility of pregnancy/period pain was discussed.
The consumer said that the provider examined her abdomen very closely: "pushing on my stomach and side so as to locate the source of my pain." He then told her the urine analysis indicated a urinary tract infection and that he was giving her Buscopan which would help with the pain and muscle spasms.
The consumer left the clinic "in extreme pain" believing that she might only have a urinary tract infection and that if this was the case someone from the clinic would contact her in two days time so that an appropriate antibiotics could be prescribed.
The next morning the consumer visited her general practitioner "in excruciating pain" and told him there was no way she could endure the pain for another day while waiting for the laboratory result. The consumer was surprised to learn that her GP had already received the laboratory report. The result was negative. After a brief discussion with and physical examination of the consumer, her GP mentioned the possibility of either appendicitis or an ovarian cyst.
Later that day the consumer was admitted to Hospital and that evening underwent an appendicectomy. The Surgical Registrar who performed the operation recorded the finding of "acute suppurative appendicitis with perforation a third of the way up from the base."
The general practitioner who provided advice to the Commissioner noted that the consumer's presentation was not typical of appendicitis. The advisor pointed out that "the pain of appendicitis is generally deemed to crescendo over 12 to 24 hrs". In contrast, the consumer presented with a three to four-day history of pain. It was also noted that the documented location of the consumer's abdominal pain, in the epigastrium and right upper quadrant, is also atypical of appendicitis.
The Code of Health and Disability Services Consumers' Rights
The following Rights are applicable:
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 - GP
In my opinion the provider did not breach Right 4(2) of the Code of Health and Disability Services Consumers' Rights.
Right 4(2)
The consumer presented with a three to four-day history of abdominal pain in the epigastrium and right upper quadrant. Neither the history nor the location of her pain was typical of peritoneal irritation that would have alerted the provider to the possibility of appendicitis.
The provider considered the possibility of period pain and ectopic pregnancy but excluded the latter with a negative test result.
Given the finding of red and white blood cells in the consumer's urine, the provider's provisional diagnosis of urinary tract infection was a reasonable one. The non-specific nature of the consumer's pain, her normal body temperature and the absence of jaundice, is supportive of the provider's "wait and watch" approach and his decision not to prescribe an antibiotic pending laboratory results.
My reviewer advised that the provider conducted an appropriate physical examination, employed appropriate diagnostic options and followed an appropriate course of treatment. In my opinion the provider provided the consumer with services that complied with reasonable professional standards and in my opinion did not breach Right 4(2) of the Code of Health and Disability Services Consumers' Rights.
Actions:
General Practitioner
Although the provider did not breach the Code of Health and Disability Services Consumers' Rights, I would like to take this opportunity to remind him of his obligation to write legibly in his clinical notes and to ensure that potential misinterpretations such as that which arose with regards to reference to "RLQ" and "RUQ", are minimised in the future.
Private Health Care Organisation
I am concerned at the inappropriate response to the consumer's complaint by the Private Health Care Organisation. Consumers may complain in any form appropriate to the consumer. The Organisation did not make adequate enquiries regarding the complaint but rather requested the consumer be more specific. While this did not deter the consumer it would deter many consumers. Complaints are an integral part of a quality process. I recommend that the Organisation review and standardise their complaint process across the Organisation.
It is noted that since receiving this complaint, the Organisation has sold this Medical Centre to another private health care organisation. A copy of this opinion will be sent to both organisations as a reminder of their obligations under Right 10 of the Code of Health and Disability Services Consumers' Rights.