Names have been removed to protect privacy. Identifying letters are assigned in alphabetical order and bear no relationship to the person's actual name.
General Practitioners
Complaint
The Commissioner received a complaint about the standard of treatment and care the consumer received from two general practitioners. In particular, her complaint was that:
- In July 1998, the consumer consulted a general practitioner at a surgery. The consumer presented with symptoms of very itchy skin and an extremely uncomfortable internal ear and throat itch. The general practitioner assured her she had an allergy of some type.
- A short time later, the consumer returned and consulted the general practitioner's locum, who stated that the previous diagnosis was incorrect and advised that the symptoms may be due to scabies or a liver complaint and took blood samples off for testing.
- Approximately two weeks later, the consumer was feeling worse and consulted a second general practitioner. This general practitioner referred to the previous blood test results but did not know what was wrong with the consumer. He stated that the locum had given an incorrect diagnosis. The general practitioner prescribed steroids and antihistamines and took more blood samples for analysis.
- Approximately ten days later, the consumer phoned the surgery as she was feeling ill and had no response from either of the general practitioners. The second general practitioner asked the consumer what she wanted him to do next. The consumer attempted to make an appointment with the first general practitioner but was told she could not see her for two days. At that appointment, the consumer presented with a lump under her armpit and in her neck. The general practitioner suspected glandular fever, prescribed antibiotics and ordered further blood tests. The consumer handed the general practitioner a letter of complaint stating how she felt she was being mistreated.
- The next day the consumer developed a lump on her chest and contacted the first general practitioner, who said she was very busy and could not see the consumer for two days.
- The consumer consulted a third general practitioner, who requested x-rays and blood tests and the next day rang the consumer with the correct diagnosis of lymphoma (cancer of the lymph nodes).
- If the consumer had been diagnosed and treated earlier the cancer would not have spread to the same extent it has now.
- Both general practitioners did not take the consumer seriously and did not follow up the numerous blood test results.
Investigation Process
The Commissioner received a complaint from the consumer on 25 January 1999. An investigation was undertaken on 24 March 1999 and information gathered from:
The consumer
First provider / general practitioner
Second provider / general practitioner
General practitioner
Consumer's sister
During the investigation the consumer's medical records were obtained. The Commissioner sought advice from an independent general practitioner.
Information Gathered During Investigation
The first general practitioner (GP) has been a registered general practitioner since 1971. She has been employed on a part time basis as an associate in a medical centre since 1984.
The consumer presented to the first GP in late July 1998 complaining of an itch on her arms, legs and feet. The consumer informed the GP that her skin irritation had been present for three to four months, ever since she had moved into her present house, which had an overgrown garden. The consumer did not have any other symptoms except the skin irritation and lesions that were caused by scratching. The GP made a diagnosis of an allergic skin reaction and prescribed an antihistamine to suppress the reaction and a lotion to soothe the skin.
The GP was on leave from the medical centre from mid-August 1998 to mid-September 1998.
The consumer returned to the surgery approximately one month later and saw the GP's locum. The consumer said to the Commissioner that she was surprised when the locum told her that the GP's diagnosis was incorrect and advised that the itching was caused by scabies or a liver complaint. The locum sent a sample of the consumer's blood for analysis and prescribed lyclear, a treatment for scabies.
The consumer informed the Commissioner that two weeks later she was feeling considerably worse. She made another appointment with the medical centre and arranged to see a different GP, as the first GP was still on leave. The records show that the consumer was in fact seen at the centre by the second GP four days later.
The consumer informed this GP that her symptoms now included nausea, painful aching underarm and considerable weight loss. The GP noted that the lyclear had been ineffective in controlling the consumer's itching skin, and that she appeared to have skin lesions as well as numerous scratch marks on her body. He examined her chest and abdomen and found no abnormality. He also checked for and found no evidence of enlarged lymph glands. The GP told the consumer that he did not think she had scabies, but that she could have hives.
The results of the blood tests requested by the locum, which were available at the time of her third consultation in late August, showed a raised Erythromycin Sedimentation Rate (ESR) of 87. The normal rate is 1-20. The second GP was concerned about this, and advised the consumer that she should have her blood tests repeated in a week. He prescribed a six-day course of the steroid Prednisone and a ten day course of Zyrec, an antihistamine. The GP ordered repeat blood tests for the consumer and asked her to return to see him if there was no improvement in her symptoms, or if she got worse.
The consumer stated to the Commissioner that the GP recognised that something was wrong, but did not know what that was. The consumer said that after ten days, in early September 1998, she was feeling very ill and telephoned the clinic as she was upset that she had not heard from them.
The GP stated in his response to the Commissioner that:
"I subsequently tried to ring [the consumer] on two separate occasions to check on her health and to ensure that she had attended for her blood test. However it appeared that her phone had been disconnected. I did not hear from [the consumer] again until [mid-]September 1998."
The consumer informed the Commissioner that when she spoke to the GP, he asked her what she wanted him to do next. The consumer had not had the repeat blood tests that the GP had requested.
In his response to the Commissioner, the GP stated:
"Talking to her [the consumer] [in mid September 1998] she told me that the treatment I had given her [in late August 1998] had worked but once she had finished the medication the itchiness had returned. She also said that she had noted a lump in her right axilla [armpit]. I asked her about the size of the lump and if there were any others elsewhere. She said that there were no others and the lump in the right axilla was not large. She requested a further course of treatment but I was concerned that she was not getting any better. I advised that it would be better to have the blood tests and once I had received the test results I would see her and reassess her condition.
My final conversation with [the consumer] was [in late September 1998]. Her results had returned and although they were a bit better they were still abnormal. I instructed the practice nurses to ring her and was told that there was no answer. It was not till late [that day] that she rang."
The consumer attempted to make an appointment on this day in late September 1998 with the first GP, who had returned from leave, however the consumer advised the Commissioner that she was told that the next available appointment was in two days. The first GP saw the consumer three days later. She presented the GP with a written complaint list detailing the events of the last two months and expressed her frustration at being "fobbed off". She felt that she had not been treated with any sense of urgency and that she had spoken to the other GP on two occasions but had not been seen.
The first GP, in her response to the Commissioner's provisional opinion, stated that:
"… [F]ive appointments were available on [the day] when [the consumer] states she was not able to be seen that day. I also detailed that I had seen her immediately [three days later] in response to her urgent request and had offered to see her on the same basis when she rang the next day but she declined. [The consumer] stated that I had said I was very busy and would not see her for 2 days - this is untrue. I came in early especially to see her [in late] September, as agreed with her, to find that she had cancelled the appointment. These facts do not fit easily with a complaint about failure to see or take seriously."
The first GP examined the consumer and found that she had enlarged lymph nodes in her right axilla, her neck and both groins. The GP examined the consumer's abdomen which was normal. The GP noted that the abnormalities in the consumer's blood had improved but decided, due to the apparent deterioration in her condition and the appearance of her enlarged lymph glands, to repeat the blood tests and test for glandular fever.
The GP, when interviewed as part of the investigation, stated:
"It's a case of 'common things occurring commonly'."
She stated to the Commissioner that she was not looking for lymphoma (cancer of the lymph nodes) as they most commonly see glandular fever in private practice.
The GP, in her response to the Commissioner's provisional opinion, stated:
"The comment 'common things occur commonly' ascribed to me has, I think, been taken out of context and was made about the diagnostic progress which is a progression through likely diagnoses, rather than a statement that we only ever look for and expect to find common illnesses."
The GP decided to commence the consumer on a course of antibiotics as an interim measure, as she suspected that she had an infection and "decided to treat her until she had evidence to the contrary".
The GP advised the consumer that a biopsy of the lymph node would be the next step.
The consumer informed the Commissioner that on the day of her biopsy appointment she telephoned the GP to say that there were further lumps developing. The consumer stated that the GP told her that she was very busy and would not see her for two days. The consumer said that as she was aware of the severity of her symptoms, she consulted a new GP.
This GP requested x-rays and blood tests and the next day telephoned the consumer to inform her that she had lymphoma, cancer of the lymph nodes.
The first GP, in her response to the Commissioner, stated:
"She had her repeat blood tests but before I received the results on the following day, I had a phone call from [the consumer] in some distress, saying that she had further lumps developing. I recall the time of the call as being after I had finished my morning surgery. I believe that I suggested she come in and see me immediately but she said she could not get time off work. I then arranged to see her the following day in her lunch hour by agreeing to come in early in my own lunch hour. The call is not documented but the appointment appears in the notes.
I arrived for the appointment only to be told that [the consumer] had cancelled the appointment because she had seen or was about to see another doctor - name not given."
The new GP telephoned the first GP a few days later to inform her that she had diagnosed the consumer as having lymphoma.
The consumer's sister informed the Commissioner in mid-August 1999, that her sister had been unsuccessfully treated with chemotherapy and bone marrow transplant by the Oncology Department at a public hospital. The consumer's sister said that the consumer was receiving Morphine and that she had stopped work to be her sister's principal caregiver.
The consumer's sister said:
"[The consumer] was treated unfairly by the [providers'] Surgery. They were just used to focussing on simple family ailments and were unable to do anything to help [the consumer]. They didn't listen to her, the Receptionist when [the consumer] was crying down the phone and saying that she wanted help, told her there were no appointments till the following day."
The Commissioner was advised by the new GP in mid-November 1999 that the consumer had died.
Independent Advice to Commissioner
My independent general practitioner advised as follows:
"This is a situation which is uncommon but is recognised as a situation whereby a patient presents with a pathology of itching and there is often no visible change in the skin apart from the complaint of the itchiness. The itchiness then later on is shown to be due to lymphoma.
The trouble is, and I have experienced such a patient myself, that at the time of the presentation when there are no such changes to be seen diagnosis is not at all clear. More often than not the diagnosis is not in fact made until the lymph glands start to appear. In this case, although the doctors could be criticised a little bit for perhaps taking too long to reach a diagnosis, nevertheless the plan had been made and the possibility raised with [the consumer] that a biopsy of a lymph gland was likely to be needed and thus a diagnosis would have been reached following that.
… The trouble is that generalised itching is not necessarily attributable to a lymphoma, although perhaps doctors need to be made more aware of this. Certainly when [the consumer] noticed that she had a number of lymph glands up, perhaps more aggressive investigations were merited at that time.
… I think that [the second GP] acted appropriately given the circumstances and the fact that he only saw [the consumer] once. … At that appointment [in late] August 1998 he prescribed her a course of Prednisone and an antihistamine on the supposition that she was suffering from an allergic reaction. This for a first consultation was not unreasonable and his recommendation that, in view of her raised ESR, this should be repeated in a week's time, was also a good one. However, I note that in fact she did not present again until some four weeks later […] and even though [the second GP] offered to see [the consumer] again after a telephone consultation, she elected not to see him and in fact saw [the first GP].
… Given the fact that this was [the second GP's] first assessment it was I think reasonably appropriate and he too was thinking along the lines of an allergic reaction. I feel that for a one-off consultation with a very unusual presentation like this [the second GP's] management was not unreasonable.
… [the consumer] consulted with [the first GP] for the first time [in late] July 1998 and at that time I feel that [the GP's] assessment was appropriate and the management was also appropriate given that this was the first time that [the consumer] had turned up with the complaint. The prescription of an antihistamine to suppress the reaction that she thought was allergic and a lotion to soothe the skin was also appropriate at that consultation.
[The first GP] did not in fact see [the consumer] again until [late] September and by this time the symptoms had been persisting. [The consumer] has seen two doctors in [the first GP's] absence on holiday ([mid]-August to [mid]-September) and she now also had lymph glands present.
At this point in time one could argue that [the GP] could have been more aggressive and diligent in pursuing the reason for [the consumer's] symptoms because by now she had evidence of an abnormal ESR, indeed this had been so for some time, and as well lymph glands were now clearly present. Perhaps it would have been more appropriate had [the GP] investigated the situation more aggressively with possible chest x-ray and ordering a lymph node biopsy, but it certainly does appear that she was thinking along these lines by what she said to [the consumer] at the time.
It is hard to understand quite why she prescribed antibiotics for [the consumer] at that time but I think that certainly by the next consultation, [the first GP] would have probably arranged to do the appropriate things.
… Although [the first GP] perhaps could have initiated investigations earlier than she had planned to, and prescribing antibiotics without any really good reason was perhaps unwarranted, nevertheless I feel that a few days difference in the overall management probably did not make a significant difference.
… Overall I believe that [both GPs] did not necessarily act incompetently, negligently and unprofessionally in not diagnosing [the consumer's] lymphoma. This was a lymphoma which presented with somewhat unusual features and I feel that they should not be unreasonably criticised for their relative tardiness in reaching a diagnosis."
The first GP, in her response to the Commissioner's provisional opinion, stated that:
"Your independent general practitioner advised that [in late] September I could perhaps have acted more aggressively and diligently given the elevated ESR and lymphadenopathy of two months duration. The first mention of lymphadenopathy is in a phone call between [the second GP and the consumer] [in mid-] September. His examination of [late] August specifically states 'no lymphadenopathy'. You state in your finding on 'Right 4(3)' … that her ESR had been identified as being elevated from [mid-] August. While this is correct, although remaining elevated, it had decreased from 93 [in early] September to 62 [in mid-] September as the laboratory reports provided to you show. This is a significant reduction. Her blood tests also showed an elevated neutrophil count, indicating possible bacterial infection, hence my decision to prescribe antibiotics. I spent a lot of time with [the consumer in late] September and had felt that I was listening to her complaints and I did attempt to assure that we would follow this through till an answer was obtained.
However, given the serious and terminal nature of [the consumer's] illness and the stress and grief involved for both [the consumer] and her family these points are probably minor. I am willing to apologise to her sister, if so directed, for any part that I have may have played in adding to their grief."
Code of Health and Disability Services Consumers' Rights
The following Rights in the Code of Health and Disability Services Consumers' Rights are applicable to this complaint:
RIGHT 4
Right to Services of an Appropriate Standard
1) Every consumer has the right to have services provided with reasonable care and skill.
3) Every consumer has the right to have services provided in a manner consistent with his or her needs.
Opinion: No Breach - Both General Practitioners
In my opinion neither of the general practitioners breached Right 4(1) of the Code of Health and Disability Services Consumers' Rights.
Right 4(1)
I accept my expert advice that the providers did not act incompetently or unprofessionally in not diagnosing the consumer's lymphoma. This was a lymphoma which presented with unusual features.
Second General Practitioner
The second GP acted appropriately given the circumstances and the fact that he only saw the consumer once. I am advised that the consultation in late August 1998, as a first consultation, was not unreasonable. His prescription of Prednisone and an antihistamine was made on the supposition that the consumer was suffering an allergic reaction. The GP recommendation that, in view of the consumer's raised ESR, that the blood tests should be repeated in a week's time, was appropriate. In my opinion the second GP treated the consumer with reasonable skill and care, and therefore did not breach Right 4(1).
First General Practitioner
The first GP's first assessment of the consumer in late July 1998, and management of her symptoms was appropriate, given that this was the first time that the consumer had consulted with her on these matters. I am advised that the GP's prescription of an antihistamine to suppress the reaction that she thought was allergic, and a lotion to soothe the skin was appropriate at that time. I am advised that the GP could have been more aggressive and diligent in pursuing the reason for the consumer's symptoms in subsequent consultations. However, this was a lymphoma with unusual features and in my opinion the first GP's actions were reasonable in the circumstances, despite not reaching a diagnosis. The GP had made a plan for the consumer's treatment, and raised the possibility with the consumer that a biopsy of a lymph gland was likely to be needed. In my opinion the first GP treated the consumer with reasonable skill and care, and therefore did not breach Right 4(1).
Opinion: Breach - First General Practitioner
In my opinion the first GP breached Right 4(3) in regard to the following:
Right 4(3)
The consumer presented at the medical centre a total of four times during a nine-week period, initially complaining of skin irritation, fatigue, weight loss and enlarged lymph glands.
The consumer consulted the first GP on her first appointment at the medical centre in late July 1998, and for the second and final time, in late September 1998. The GP was following a line of investigation which included repeat blood tests leading to chest x-ray and lymph gland biopsy.
The consumer did not feel that her needs were met in a timely manner. She was increasingly distressed by her worsening condition and frustrated by the GP's lack of action. The consumer presented the GP with a written complaint list in late September 1998, detailing her concerns about the events of the last two months, and expressed her frustration at being 'fobbed off'. The consumer informed the GP that she felt that she had not been treated with any sense of urgency.
When the GP saw the consumer in late September 1998 her symptoms had been persisting for eight weeks. Her ESR had been identified as being elevated from mid-August 1998 and she was now presenting with enlarged lymph glands. I am advised that the GP could have been more aggressive and diligent in pursing the reason for the consumer's symptoms.
In my opinion the GP did not address the consumer symptoms in a timely manner consistent with her needs and in these circumstances breached Right 4(3).
Actions
I recommend that the following action is taken:
- That first general practitioner apologises in writing to the consumer's sister for her breach of Right 4(3) of the Code. This apology is to sent to the Commissioner who will forward it.
Other Actions
A copy of my opinion will be sent to the Medical Council of New Zealand. A non-identifying copy of my opinion will be sent to the Royal New Zealand College of General Practitioners for educational purposes.