Names have been removed to protect privacy. Identifying letters are assigned in alphabetical order and bear no relationship to the person's actual name.
Dr B, General Practitioner
Dr C, General Practitioner
A Report by the Health and Disability Commissioner
Parties involved
Master A Consumer
Mr A Complainant, Consumer's father
Mrs A Complainant, Consumer's mother
Dr B Provider, General Practitioner
Dr C Provider, General Practitioner
Dr D Paediatrician, Public Hospital
Dr E Diabetologist
Dr F General Practitioner
Complaint
On 9 October 2003 the Commissioner received a complaint from Mr and Mrs A about the services provided to their son, Master A, by Dr B and Dr C. The following issue was identified for investigation:
Whether Dr C and Dr B, general practitioners, provided Master A with services of an appropriate standard in July and August 2003. In particular, whether they:
- properly assessed and managed Master A's condition which included symptoms of excessive thirst, weight loss, urinary incontinence at night and random high blood glucose levels.
An investigation was commenced on 27 November 2003.
Information reviewed
Information from:
- Master A
- Mr A
- Dr B, including:
- correspondence
- medical notes
- Dr C, including:
- correspondence
- medical notes
- Public Hospital, including:
- Master A's clinical notes
- Dr D, including:
- correspondence
- Dr F, including:
- Dr F's clinical notes
- Dr E
- Independent expert advisor Dr Shane Reti, a general practitioner in rural practice.
Information gathered during investigation
Mrs A has type II diabetes. When her son, Master A, aged 12, complained of being excessively thirsty, Mrs A randomly tested his blood sugar levels two or three times on her testing device. The results indicated that his levels were in the mid-twenties (normal range is 3.5-7.8). On 14 July 2003 Mrs A made an appointment at the rural practice for Master A because she was also aware that diabetes can run in families and was concerned that his bedwetting could be another symptom.
Master A had a consultation with general practitioner Dr B on 15 July 2003. His father was also present. Dr B confirmed that she was told that Master A had had a "few episodes of bed-wetting" over the past two or three weeks, which Mr A described as unusual for Master A. Dr B noted that Mrs A had a history of sarcoidosis, diabetes inspidus and diabetes mellitus. Dr B's notes describe Master A as being asymptomatic.
Master A told Dr B that he had eaten a chocolate bar half an hour prior to his mother performing the blood glucose test. Master A recalled that Dr B was also informed that he felt unwell in the mornings and had been vomiting. However, he later advised me that he could not remember much of the detail of the consultation with Dr B. Dr B recalled that, when asked specifically, Master A denied having symptoms of excessive urination (polyuria), increased thirst (polydipsia) or weight loss.
Mr A stated that he also told Dr B that Master A had lost a small amount of weight (although he attributed this to recent change in the family's lifestyle) and had excessive thirst and was unusually tired.
Dr B requested a full blood count and blood tests for non-fasting serum glucose, renal and liver function, iron and non-fasting lipids. Master A was not able to provide a urine specimen for testing at the time of the consultation.
Dr B informed Master A and his father that they would not be contacted unless the laboratory results were of concern. Mr A was advised that if he was concerned about Master A's condition, he should be reviewed by a doctor.
The blood tests were reported on Thursday 17 July 2003. The laboratory reported that Master A's serum glucose (17.6mmol/L, normal range 3.5-7.8), glycated haemoglobin (8.1%, normal range 4.0-6.0), total bilirubin (17mmol/L, normal range 0-15) and alkaline phosphatase (639 IU/L, normal range 85-460) levels were high. Dr B attempted to contact Mr and Mrs A without success. Dr B's practice nurse managed to contact Mrs A on 18 July to tell her that, in light of abnormal laboratory results, Master A needed to be seen by a doctor that day.
As Dr B was not working that day, her colleague, general practitioner Dr C, assessed Master A, who was again accompanied by his father. Dr C recorded that he discussed the laboratory results. He thought that Master A probably had type I diabetes mellitus and recommended that a glucose tolerance test (GTT) be done. Mrs A, who is a medical scientist, decided not to follow this advice, as she was aware that her laboratory's policy was not to conduct GTT tests on patients with a recorded blood sugar level greater than 11.0mmol/L.
Dr C recalled that Master A denied any symptoms of diabetes despite specific enquiry. Dr C cannot recall what specific questions he asked but his usual practice when he suspects diabetes is to ask whether a patient has polydipsia, polyuria, nocturia (including bed-wetting), abdominal pain, nausea, lethargy or fatigue, weight loss, appetite and sensory changes in the hands and feet. Dr C acknowledged that he was aware that Master A had reported nocturnal enuresis (bed-wetting) but he was unclear whether this was ongoing. He did not conduct a urine test as he believed that Master A was asymptomatic and he did not suspect ketoacidosis.
Mr A advised me that he informed Dr C that Master A had lost weight. Master A stated that Dr C was also told that he had excessive thirst, felt unwell in the mornings, wet his bed and had been vomiting. Dr C disputes that he was given this information.
Dr C recommended a referral to Dr E, a diabetologist in a larger city. Mr A understood that Master A was referred to Dr E because there was no specialist diabetic clinic at the local Public Hospital. Dr C denies that he said this and says that he explained it was because there was no diabetologist at the Public Hospital. Mr A told Dr C that he would discuss the proposed referral with his wife and get back to him.
Mr and Mrs A decided that they wanted to have Master A seen by Dr E, and Mr A conveyed this to Dr C on 22 July. Accordingly, Dr C faxed a referral to Dr E on 24 July headed "Newly diagnosed Type I Diabetes Mellitus". The letter went on to state:
"This youngster presented to this practice for the first time on 15 July 2003 having recently moved to the area from [a city]. His mother suffers from sarcoidosis, Diabetes Mellitus and Diabetes Insipidus. The family have checked [Master A's] BSLs randomly using his mother's glucometer and were concerned with consistently high readings and brought him for review. His HbA1c was found to be 8.1% with a glucose (?fasting - there is some doubt as to whether or not he had eaten) of 17.6 mmol/L. I have requested a GTT and advised further regarding diet etc. After extensive discussion, and on my recommendation, the family have requested referral to a Diabetologist and I would be most grateful if you would assess and advise."
Dr C confirmed with Dr E's secretary that the fax had been received. Master A was given an appointment for 28 August 2003. Dr C was not informed of the date of the appointment and did not see Master A after 18 July 2003. Dr C stated that he had expected that Master A would be seen by Dr E within two weeks and that, in the interim, he was not informed by Mr or Mrs A of any change in Master A's condition. He added that, at the time he saw Master A, he did not think that his condition warranted referral to hospital.
Master A presented to the Emergency Department (ED) at the Public Hospital at 4.05pm on 21 August 2003. He had had a random blood glucose level of over 20. The ED notes record that Master A had been assessed by his GP and referred to Dr E in the city. While awaiting an appointment with Dr E, Master A had started eating an appropriately modified diet, but his blood sugar levels were consistently between 20 and 30 (as measured using his mother's testing device).
The ED notes record that Master A had been lethargic, vomited in the morning, and was drinking and urinating excessively over the previous week. Master A was also reported as having experienced blurred vision and a headache at school earlier in the day.
The laboratory reported a midstream urine test as "ketones ++", his blood sugar level was 18.0mmol/L and his haemoglobin level was 153g/L. Master A was diagnosed with type I diabetes, admitted to hospital, and administered an intravenous infusion of insulin.
Independent advice to Commissioner
The following expert advice was obtained from Dr Shane Reti, general practitioner:
"My name is Dr Shane Reti and I am a registered medical practitioner working in general practice in Whangarei for the past 14 years. My qualifications are as detailed on the letterhead. Further experience to offer comment on this matter would include working as a PRIMEX examiner for the RNZCGP years 1999-2003, as the sole doctor at a weekly rural marae based clinic, and as an expert advisor to the Health & Disability Commissioner from 1998.
I would state the following:
- I have read and agreed to the guidelines forwarded to me by the Commissioner's office as Appendix H 'Guidelines for Independent Advisors'.
- I acknowledge receipt of information pertaining to this matter as forwarded to me by the Commissioner's office as detailed under 'supporting information' on page 3 of the initial request for advice. As far as the information presented to me is accurate, I have based my opinion on this information.
- Miscellaneous - subsequent to my request, I acknowledge receipt of further information from the investigator dated 3.8.2004.
- Further Opinion - I would also state that in a completely anonymous manner, the key features of this case have been presented by me to a [local] GP peer group for further canvassing of views and opinions.
This report will address the questions directed to me on pages 3-5 of the request for expert advice dated 7 July 2004 and forwarded to me by the investigator, notwithstanding the further information provided to me as in clause 3 above.
[Dr B]
Did [Dr B] appropriately assess and manage [Master A's] condition at the consultation on 15 July 2003?
Scenario A. In my view [Master A] was not appropriately assessed or managed and required urgent further investigations on the basis of:
- a history of a significantly elevated blood sugar in the mid 20's by a family member regardless of whether [Master A] had had a recent chocolate bar or not
- family history of diabetes
- recent episodes of bed wetting.
Scenario B. The symptoms detailed under this scenario, namely weight loss, excessive thirst, unusual tiredness, and vomiting significantly elevate the level of urgency above that detailed in scenario A above.
What other investigations, if any, should [Dr B] have requested or conducted?
It would be most appropriate at this consultation, to have undertaken a blood sugar recording such as a BM, to confirm the current glucose status in the patient's blood. This would be especially prudent in this situation because:
a. The patient was unable to produce a urine sample
b. The practice nurse had drawn blood for further investigations anyway.
Should [Dr B] have referred [Master A] for immediate assessment and treatment to [the Public Hospital]?
Scenario A. Yes. At a minimum, [Dr B] should have taken immediate advice from a specialist. Scenario B. Yes. With even greater urgency, immediate advice should have been sought from a specialist.
- If the serum glucose result reported by the laboratory (17.6) had been a fasting result, what difference, if any, would this have made to [Master A's] management?
A fasting result of this magnitude would indicate more severe diabetes than a non-fasting result, and would warrant increased urgency for specialist advice.
2. [Dr B] advised that she was unsure of the significance of [Master A] wetting his bed. Was this likely to have been a symptom of diabetes? If so, should [Dr B] have recognised this?
In the context of the other symptoms, and the clear focus on diabetes diagnosis, it is very likely that this symptom was caused by diabetes. In this situation then it would be reasonable to expect the bed wetting to be an associated symptom of diabetes.
What difference, if any, would it make to your advice if [Dr B] was informed by [Master A] and [Mr A] that [Master A] had lost weight, had excessive thirst, was unusually tired, unwell in the mornings and had been vomiting?
The advice given would not change in that there was enough evidence at the first consultation to seek specialist advice. These further symptoms significantly increase the urgency with which that advice should be sought.
[Dr C]
Did [Dr C] appropriately assess and manage [Master A's] condition at the consultation on 18 July 2003?
Scenario A. In my view [Master A] was not appropriately assessed or managed and required urgent further investigations on the basis of:
-
- a history of a significantly elevated blood sugar in the mid 20's by a family member regardless of whether [Master A] had had a recent chocolate bar or not
- family history of diabetes
- recent unusual episodes of bed wetting
- laboratory confirmation of an elevated blood glucose (17.6).
Scenario B. The symptoms detailed under this scenario, namely weight loss, excessive thirst, unusual tiredness, unwell in the mornings and vomiting significantly elevate the level of urgency above that detailed in scenario A above.
What other investigations, if any, should [Dr B] have conducted or requested? In your response please include advice on whether [Dr C] should have physically examined [Master A], requested a urine sample for testing and whether it was appropriate to recommend a glucose tolerance test.
[Dr C] should have physically examined [Master A] to assess his immediate condition as it relates to potential diabetes complications such as ketoacidotic coma and dehydration. As part of that examination, a urine test would also add further information towards overall diabetes status. A glucose tolerance test in this instance is likely to have been unhelpful and unnecessary, with some laboratories refusing to even undertake such testing at the blood glucose level already revealed (17.6), because a diagnosis of diabetes is already clear.
Should [Dr C] have referred [Master A] for immediate assessment and treatment to [the Public Hospital]?
[Dr C] should have sought immediate specialist advice as to further management.
[Dr C] stated that he expected [Dr E] to assess [Master A] within about a week to ten days. If you consider that [Master A] did not require immediate assessment and treatment was the referral reasonable?
NA
Did the referral to [Dr E] appropriately describe [Master A's] condition and priority for treatment? In your response please include advice on whether the referral should have indicated that [Master A] was not treated with insulin and have been marked urgent.
The referral to [Dr E] ideally should have been marked urgent, should have detailed what the current management plan was if any, and should have contained some of the relevant symptoms detailed under scenario A and scenario B. Somewhat mitigating the lack of 'urgency' labelling however, is the implicit urgency contained in detailing the initial diagnosis of 'Newly Diagnosed Type 1 Diabetes Mellitus', and the fact that this was a child. To that effect, while the referral was not labelled as 'Urgent', it is reasonable to anticipate that some degree of urgency would intrinsically be associated with the details that were provided.
Should [Dr C] have discussed [Master A's] condition with [Dr E] when he wrote the referral?
Specialist advice was appropriate from the first consultation.
Should [Dr C] have confirmed the date of [Master A's] appointment with [Dr E] or [the A family]? If so, when?
Immediate specialist advice was the most appropriate action.
What difference, if any, would it make to your advice if [Dr C] was also informed by [Master A] and [Mr A] that [Master A] had lost weight, had excessive thirst, was unwell in the mornings and been vomiting?
See point 1 Scenario B above
In summary, it is my view that there was evidence for [Master A] having diabetes at an urgent level from the first consultation. It is also my view that immediate specialist advice should have been sought from the first consultation, and failing that, at each and every further interaction."
Subsequent events
Responses to provisional opinion
Dr B made the following comments in response to my provisional opinion. She said that, at the time that Master A presented to her, he did so as an asymptomatic child with a few recent incidents of bed-wetting. She explained that, had she been told that his symptoms had been going on for two weeks, this would have implied a degree of significant urgency.
Dr B reiterated that she had wanted a urine sample from Master A to test for ketones and glucose to see if the bed-wetting was due to a urinary infection. She chose not to do a fingerprick test as she already knew there had been an elevated reading and she believed that a laboratory test would be more accurate. She concluded by saying that, had Master A not been asymptomatic, and had he not looked so strikingly well at the consultation, her index of suspicion would have been higher. As soon as the blood tests became available she tried to contact Mr A, with a view to getting him to take Master A to the hospital. Dr B was not at work when Mr A was contacted, but was later told that an urgent referral had been made.
Dr B expressed her regret for the unfortunate delay and Master A's subsequent hospitalisation and provided a letter of apology for the A family.
In response to my provisional opinion, Dr C advised that his actions in arranging an assessment for Master A were reasonable. In his view, Master A required urgent assessment (rather than an emergency hospital assessment) because, although he had experienced bed-wetting and had a high blood sugar reading, he was asymptomatic. However, the urgency of Master A's situation would "best be judged" by Dr E in light of his significant expertise in diabetes. Dr C did not receive permission from Master A's parents to make a referral to Dr E until the following week. He was unable to contact Dr E by telephone to discuss Master A's condition after he faxed the referral on 24 July. Dr C confirmed with Dr E's secretary that she would draw his attention to the referral. He expected that Master A would be assessed by Dr E within two weeks. Dr C told Mr A to contact him if Master A's condition deteriorated.
Further expert advice
Dr Reti provided further expert advice in light of the responses of Dr B and Dr C. Dr Reti advised that:
"[Dr C]
- I accept that [Dr C] did take extra steps towards checking that the referral did reach [Dr E]
- However, this is verifying a step 'towards' a management plan, and not verifying the actual management plan itself
- [this response] suggests that [Dr C] is comfortable with a default 2/52 delay on [Dr E's] part, again failing to recognise the immediacy of the situation.
In summary, it is my opinion that steps were taken towards seeking specialist advice, but these steps were not concluded to a degree that produced a definitive and timely management plan as was the responsibility of the referring doctor.
[Dr B]
I have nothing further of substance to add to my previous correspondence."
Apology
In light of Dr C's response to the provisional opinion and Dr Reti's further expert advice, additional information was requested from Dr C. Dr C responded by providing a written apology for Master A and his family. He also advised:
"I believe that I take, and have always taken, Diabetes Mellitus very seriously - especially in children and Type I Diabetes. It has always been my practice to refer symptomatic paediatric Diabetes emergently and asymptomatic Diabetes urgently. I accept that there was an unacceptable delay in [Master A] being seen and acknowledge my role in this. I sincerely apologise for any distress that I may have caused to [Master A] and his family for any action or inaction on my part. I believe that I have learned from this and now refer ALL Paediatric Diabetes, symptomatic or otherwise, emergently/immediately."
Code of Health and Disability Services Consumers' Rights
The following Right in the Code of Health and Disability Services Consumers' Rights is 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.
Opinion: Breach - Dr B
The Code states that patients have the right to have services provided with reasonable care and skill. Right 4(1) applies to the care and treatment provided to Master A.
Dr B was aware at the consultation on 15 July 2003 that Master A's mother's family had a history of diabetes, that Master A had a high blood glucose test, and that he had recently experienced episodes of bed-wetting. Dr B stated that when she asked Master A specifically about symptoms of diabetes such as polyuria, polydipsia and weight loss, he denied having these symptoms.
Master A recalled that Dr B was told he felt unwell in the morning and had bed-wetting, but could not remember much of what happened during the consultation with Dr B. Mr A said that he told Dr B that Master A had lost weight recently, although he attributed it to recent change in the family's lifestyle.
In any event, in light of Dr Reti's advice it is not necessary for me to determine whether Master A reported symptoms of polyuria, polydipsia or weight loss. According to Dr Reti, Master A's previous blood glucose level (whether or not it was a fasting sample), his family history of diabetes and his recent history of bed-wetting should have prompted Dr B to take a blood sugar level (a BM test) during the consultation, to confirm his current glucose status. Furthermore, Dr Reti advised that Master A should have been referred for immediate specialist advice.
I accept Dr Reti's advice. Dr B was provided with sufficient information to warrant further investigations and immediate specialist advice, irrespective of whether Master A or his father also informed her of symptoms of polyuria, polydipsia and weight loss. In my opinion, Dr B breached Right 4(1) of the Code in failing to assess Master A's blood sugar level during the consultation and seek immediate specialist advice. I appreciate that Dr B took steps to ensure that Master A was promptly reassessed in light of the blood test results. However, although this was commendable, Master A's condition at the consultation on 15 July 2003 warranted immediate action.
Opinion: Breach - Dr C
A number of sources of information were available to Dr C at his consultation with Master A. Dr C was aware of Master A's previous high blood glucose, as recorded by his mother's blood testing device. Furthermore, the blood tests previously ordered by Dr B confirmed that Master A had an elevated blood glucose level of 17.6. Dr C was also aware of Master A's family history of diabetes and that he had recently been wetting his bed.
During the consultation, Dr C recommended that Master A undertake a glucose tolerance test (GTT). Dr Reti stated in his report that he felt a GTT was unnecessary and unhelpful and commented that some laboratories refuse to undertake GTT testing in patients with a blood glucose level similar to Master A's, because a diagnosis of diabetes is already clear.
Dr Reti advised that, in light of the information Dr C had before him at the outset of the consultation, Master A's symptoms urgently required further investigation. Dr C ought to have examined Master A to determine whether he was developing diabetes complications such as ketoacidotic coma and dehydration. Dr C should also have ordered a urine test. In addition, in Dr Reti's view, Dr C should have sought immediate specialist advice about the management of Master A's condition and made arrangements to monitor and treat Master A prior to any specialist appointment.
In referring Master A to Dr E, Dr C should probably have flagged the referral as being urgent, although the heading "newly diagnosed Type I Diabetes Mellitus" implicitly conveyed a sense of urgency about the referral. However, ideally the letter should have explained in more detail Master A's symptoms and outlined the current management plan for Master A's condition pending review by Dr E.
I accept Dr Reti's advice. Master A's confirmed blood test results should have alerted Dr C to the seriousness of his condition, the need for a physical examination to rule out any serious complications of elevated blood glucose levels, and the need for immediate specialist attention to help stabilise his diabetes. Dr C did not appreciate the seriousness of Master A's condition. He made no arrangements to monitor or treat Master A prior to his appointment with Dr E, and did not mark the referral as "urgent".
Dr C should either have telephoned and personally spoken to Dr E, and then discussed an interim management plan with Master A and his parents, or immediately referred Master A to the diabetic clinic at the Public Hospital (in which case a telephone call would still have been warranted). Referring Master A to Dr E with an unconfirmed expectation that he would be seen within two weeks was an inadequate response, as Dr C has now acknowledged.
Dr C claims that he did not have confidence that the local Public Hospital would be able to treat Master A within a two-week period. However, there is no evidence that he contacted the local hospital to find out how promptly a child with a blood sugar reading of 17.6 could be seen. Instead, Dr C assumed there would be a delay at the local hospital, but made no effort to expedite the specialist referral to Dr E in the city.
Master A's deterioration over the month following his 18 July 2003 consultation with Dr C, before his acute presentation at the Public Hospital Emergency Department on 21 August 2003, could and should have been prevented. Master A and his parents did not receive the quality of care that they were entitled to from their general practitioner.
Conclusion
Accordingly, in my opinion, Dr C breached Right 4(1) of the Code by not properly assessing Master A's condition, not ensuring that Master A received immediate specialist treatment, and failing to implement an appropriate management plan pending specialist review. Irrespective of the dispute about what information was conveyed about Master A's current symptoms, Dr C had sufficient information before him to warrant seeking immediate specialist advice to ensure that Master A's condition was properly managed from that point on. It is not sufficient for a general practitioner to respond to a new diagnosis of a serious condition by sending (even by facsimile) a letter of referral to a specialist. Newly diagnosed patients rely on their general practitioner to help them navigate the health system and to give practical advice about managing their condition pending specialist review.
However, I commend Dr C for apologising to Master A and his family and reviewing his practice in light of the incident.
Actions taken
- Dr B and Dr C have apologised to Master A and his parents for breaching their rights under the Code.
- Dr B and Dr C have reviewed their practice in light of this report, in particular in relation to the diagnosis and management of diabetic conditions.
Follow-up actions
- A copy of this report will be sent to the Medical Council of New Zealand and the Royal New Zealand College of General Practitioners.
- A copy of this report, with details identifying the parties removed, will be sent to the New Zealand Rural General Practice Network and placed on the Health and Disability Commissioner website, www.hdc.org.nz, for educational purposes.