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MEDICAL PROTECTION SOCIETY
VOl. 17 nO 3, SEPTEMBEr 2009
IRELAND
Casebook
Cauda equina
syndrome
rare condition, high medicolegal profile
Transforming your practice
liability for others’ errors
case reports
PrOFESSIOnAl SUPPOrT AnD EXPErT ADVICE
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MPS0898:08/09

Contents
Update 4–6
Faxing referrals is risky, warns MPS
Consultants warned about locum work
New breast cancer guidelines for GPs
New registration rules
New GP contract talks planned for 2010
MPS launches guide to consent
Articles 7–14
Liability for others’ errors 7
Claims and Legal Services Director, Sarah Venus,
explains the situation.
Small changes, big results 8–10
Gareth Gillespie and Julie Wilson look at the ways
in which MPS’s risk assessments can drastically
overhaul your practice.
Cauda equina syndrome 11–14
Alan Gardner and Tim Morley look at a rare, debilitating
condition with a signifi cant medicolegal profi le.
Case reports 15–25
Introduction – On the case 15
Dysphasia – dysuria – disaster 16
A long-lasting earache 17
Don’t be blind to red flags 18
Don’t drop the baton 19
Consent? No sweat 20
An unnecessary operation or two 21
Too little, too late 22
Difficulty getting through 23
Not just another headache 24
A failure of communication 25
Reviews 26
We review How Doctors Think.
Over to you 27
Your responses to the May issue of Casebook.
Page 17
Page 19
Page 24
Editorial
As we face up to the reality
of a worldwide “swine
fl u” pandemic, we have
an opportunity to refl ect
on our reactions to such
a situation and how we
communicate them.
While we anticipate and prepare for such an
eventuality, there is a sense that we never
quite believe that it will actually come to
pass. But when it does, how good are we at
responding to the threat? And how good are
we at communicating the risks involved, and
assigning the right level of proportionality to
those risks?
It is always the case that mixed messages will
exist in these circumstances, with competing
sources giving out confl icting signals. On
the one hand we are told that the current
H1N1 virus is a mild one; on the other, we
are confronted with alarming statistics about
infection rates and regular updates on the
number of people who have died from the
virus. Delivering accurate and responsible
messages in the context of such a rapidly
evolving situation is diffi cult.
Coupled with this is an increasingly risk averse
society for whom the idea of people dying
from such a seemingly everyday virus as “fl u”
provokes indignation – we need someone
to blame. In fact, it is a reality check, and for
two reasons: fi rst is the fact that seasonal
fl u is in itself a killer, particularly for those
with underlying medical conditions (although
without the same publicity); secondly, it
demonstrates the limitations of human
intervention in the face of this type of natural
threat. As medical professionals we should
always be aware of the expectations placed
upon us, but also be aware of our limitations.
And indeed the limitations of what people can
reasonably expect of us.
Dr Stephanie Bown
Editor-in-chief, MPS Director of Policy
and Communications
EDITOR-IN-CHIEF Dr Stephanie Bown EDITOR Gareth Gillespie EDITORIAL CONSULTANT Dr Su Jones MEDICAL WRITER Dr Mónica Lalanda
WRITERS Rachel Seddon, Sara Williams DESIGN Cambridge Publishers PRODUCTION MANAGER Philip Walker EDITORIAL BOARD Dr Tina
Ambury, Dr Paul Farrugia, Dr Lyn Griffi ths, Dr John Lourie, Dr Angelique Mastihi, Dr Amanda Platts, Dr Frank Rugman, Rachel Morris, Jon Golding
LAYOUT BOARD Dr Nick Clements, Dr Tim Hegan, Dr Graham Howarth, Dr Ming Teoh, Dr Marika Davies, Dr Bryony Hooper, Dr Peter Mackenzie,
Dr Andrew Pickering, Jon Golding
CASE REPORT WRITERS Sandy Anthony, Dr Samuel Dresner, Dr Anna Fox, Dr Chris Godeseth, Dr Sean Kavanagh, Dr Mónica Lalanda,
Dr Gerard McKeague, Dr Zoe Schaedel, Dr Raj Thakkar
PRINTED BY TU Ink
Opinions expressed herein are those of the authors. Pictures should not be relied upon as accurate representations of clinical situations. ©The Medical
Protection Society Limited 2009. All rights are reserved.
ISSN 1740 0120
PLEASE ADDRESS CORRESPONDENCE TO:
Casebook Editor, Medical Protection Society, Granary Wharf House, Leeds LS11 5PY, UK. casebook@mps.org.uk
Casebook is produced three times a year by the
Communications Department of the Medical Protection
Society (MPS). Regional editions of each issue are
mailed to all MPS members worldwide.
GLOBE (logo) (series of 6)® is a registered UK trade
mark in the name of The Medical Protection Society
Limited.
Current and previous issues of Casebook and additional
content are available at www.mps.org.uk
MPS is not an insurance company. All the benefi ts of
membership of MPS are discretionary, as set out in the
Memorandum and Articles of Association.
Cover: © medical RF.com/sciencephotolibrary
www.medicalprotection.org IRELAND CASEBOOK VOL. 17 NO. 3, SEPTEMBER 2009
3

MPS UPDATE
Talking
quality
MPS Medical Director,
Dr Priya Singh, explains
how your feedback shapes
quality assurance at MPS
Providing members with the
highest quality of service at
all times underpins everything
that we do. So thank you
those who contributed to
the online and paper surveys
over the last year. Thank you
particularly for comparing
MPS so favourably to other
service organisations and for
strongly recommending MPS
to colleagues.
However, during July/August,
we realised that some
members had experienced
difficulty in reaching our
membership team by
telephone. My apologies if you
personally have experienced
delays. I would like to let you
know that the higher than
usual demand, even for a peak
period, for membership advice
has been recognised and we
have put in place solutions
which will ensure that you can
speak with a membership
adviser promptly.
It is important that we keep
asking ourselves questions
about service, regardless
of how good the feedback
has been. With that in mind,
this year we piloted an extra
element – contacting you
by telephone to ask for your
views about the service you
had received. I have to say
that I thought long and hard
about whether or not to
introduce this element, as I
appreciate how busy you are,
and so decided that sending
an email in the first instance
would allow people to opt out
I am very pleased
to report that many
members were
willing to take part
in the telephone
survey, and this
has allowed us
not only to gather
information, but
also to discuss
MPS services
and your needs in
greater detail
of receiving a call. I am very
pleased to report that many
members were willing to take
part in the telephone survey,
and this has allowed us not
only to gather information, but
also to discuss MPS services
and your needs in greater
detail.
Your feedback is vital to the
shaping of MPS, so thank you
in advance for participating in
the coming year.
Quality assurance
Our annual surveys ask for the
views of members who have used
our services – either for advice or
membership information. In both
areas members have again given
our services an exceptionally high
rating.
Medicolegal advice
n 88% said they would
recommend MPS medicolegal
and legal services to colleagues
n 93% gave an overall score of
their experience of good, very
good or excellent
n 84% said that the service
they received from the MPS
medicolegal adviser they
spoke with was better than
other service organisations
they dealt with.
Member comments on the
medicolegal advice received
include: “Excellent and prompt
advice – very reassuring”
“Very clear advice, with empathy
and understanding”.
As well as your print copy of
Casebook, all members can
now receive the journal in
electronic format.
From the May edition,
Casebook has been available
in a new format whereby it
is possible to turn the pages
electronically, add bookmarks
to mark pages of interest
and jump to an article – all at
the click of a mouse. If you
have not yet seen the digital
edition of Casebook, visit the
MPS website, or keep an eye
out for an email from us.
Membership services
Precentage scoring good, very
good or excellent:
n Speed of response – 94%
n Ability to understand the
query – 95%
n Tone/professionalism of the
reply – 97%
n Clarity of information given –
95%
n Success in resolving the
query – 95%
n Overall satisfaction – 94%
Precentage scoring better or
much better:
n Service compared to other
service organisations they
deal with – 88%.
Member comments received
on Membership services
include: “I was given prompt
and helpful advice”
“I found the team very
knowledgeable and helpful”
“Very efficient and
professional”.
Casebook turns
a corner
By offering Casebook in
this format, MPS hopes
to provide all members
with a convenient way
to access the journal in
a time and place to suit
you. It will not replace the
print edition, but should be
seen as an added benefit
of membership – allowing
you unrestricted access to
Casebook’s useful features,
case reports and active
links to further information
– proving invaluable if you
misplace your printed
copy.
4
ireland casebook vol. 17 no. 3, SEPTEMBER 2009
www.medicalprotection.org

international update
WMA hears medical
voice on climate
change
The World Medical Association
(WMA) hosted a seminar in
Copenhagen in September to
hear the medical profession’s
voice on the consequences of
climate change.
Doctors’ leaders and climate
change experts shared their
views on the new global climate
treaty, which will be considered
in November to replace the
Kyoto Accord.
NEWS IN BRieF
Guidelines needed for
informing patients of
medical errors
National guidelines are needed
for timely disclosure of medical
errors and informing patients,
argue Canadian researchers.
Writing in the Canadian Medical
Association Journal, Dr Roger
Chafe et al argue that while
there are guidelines outlining
how healthcare providers
communicate medical errors to
patients, few exist in Canada or
other countries for disclosing
errors affecting large numbers
of patients.
They also highlighted the health
impact of climate change and
debated the role doctors could
play in alerting the world to the
increased risk of disease.
They call for clear
communications, an external
analysis to identify cause and a
review that focuses on actions
to ensure quality of care rather
than punishment.
n www.cmaj.ca
Neurosurgeons
highest paid when
qualified
US neurological surgeons
who have just completed their
training earn more than any
newly qualified doctors in their
first year, according to a survey
of doctors’ recruiters.
Dr Otmar Kloiber, secretary
general of the WMA, said: “It is
vital that health is fully considered
in current global debates and
that physicians are provided
with accurate information and
awareness-raising tools to
advocate action at a national level.
“The WMA is preparing major
new policy for physicians
in areas such as advocacy,
capacity building and
collaboration. We hope to
adopt this at our annual
General Assembly in New Delhi
in October so that it can be fed
into the United Nations climate
change conference being held
in Copenhagen in December.”
n www.wma.net
Last year, neurological
surgeons earned a median
salary of US$445,000
in their first year after
completing their residency or
fellowship. Other specialties
paying high salaries in their
first year after residency
or fellowship include
invasive and interventional
cardiology, haematology
and oncology, maternal and
foetal medicine, general or
orthopaedic surgery and
diagnostic and interventional
radiology.
n www.bmj.com
Doctors urged to consult on EMA policy
Doctors have until the end of
September to comment on the
European Medicines Agency
(EMA) draft transparency policy.
The policy focuses on three
main objectives to achieve
absolute transparency:
n More transparency of daily
operations – will lead to
more proactive disclosure
of information about the
scientific evaluation of
medicines and increased
understanding of how the
agency reaches scientific
conclusions
n Strengthen the agency’s
interaction with its
stakeholders – more
healthcare professionals will
be consulted on the scientific
evaluation of medicines in the
agency’s scientific committees
© jupiterimages
n Promote a harmony and
consistency across the
European medicines network
– the agency will be working
closely with the medicines
regulatory authorities across
the EU.
The final adoption and
publication of the policy will be
at the end of 2009.
n www.emea.europa.eu
WMA reminds
doctors of their
ethical obligations in
relation to torture
At its council meeting in Tel Aviv,
the World Medical Association
(WMA) reminded doctors of their
ethical obligations in relation to
torture and interrogation.
Doctors were reminded that
they were strongly prohibited
from participating in or even
being present during the practice
of torture, or other forms of
cruel, inhuman or degrading
procedures.
The reminder follows a report
that acknowledges unsettling
practices by some health
professionals, including direct
participation in the infliction of ill
treatment, monitoring specific
methods of ill treatment and
participation in interrogation
processes.
Dr Edward Hill, chair of the
WMA, said: “It is quite clear that
any involvement by physicians
in torture is fundamentally
incompatible with their role as
healers. It violates the essential
ethical obligations on all
physicians to ‘first do no harm’
and to respect human dignity. As
the world’s largest association of
physicians and the voice of the
medical profession, the WMA
will work to ensure that these
core principles guide physicians
worldwide.”
The resolution also urged
national medical associations to
inform doctors and governments
about the Declaration of
Hamburg and its contents, and
urged them to speak out in
support of the basic principles
of medical ethics and investigate
any breaches by their members.
n www.wma.net
www.medicalprotection.org ireland casebook vol. 17 no. 3, SEPTEMBER 2009
5

IRELAND UPDATE
Faxing referrals is risky, warns MPS
Doctors are being warned
about sending confidential
patient information via fax,
following security concerns.
MPS has dealt with many cases
where information has been
picked up by the wrong person,
often because of misdialling
or out-of-date fax numbers.
This can mean that patient
confidentiality is breached and
treatment is delayed.
MPS reminds members that,
in accordance with the Medical
Council’s A Guide to Ethical
Conduct and Behaviour (2004),
all doctors have a responsibility
Consultants warned about locum work
The HSE has reminded doctors
who are not on the Specialist
Register that they are not
permitted to take up locum
consultant posts that last for
more than three months.
to ensure that any data about
patients is kept secure.
Doctors are advised to:
n Only use fax machines to
send sensitive data if it is
absolutely necessary to do
so; for example, for urgent
referrals, and when no other
means of requesting the
referral is available
n Ensure any fax machines are
only accessible to authorised
staff, and are placed in a
secure location
n Check with the intended
recipient before sending
that incoming faxes are only
picked up by authorised staff,
This is based on paragraph
8.2 of the Medical Council’s
specialist division application
guide, which was updated in
June 2009. It specifies that
only medical practitioners who
and ask them to confirm
when it has been received
n Use pre-programmed fax
numbers wherever possible,
to avoid the risk of misdialling
a number when sending
sensitive information
n Send a cover sheet along
with the fax, containing a
confidentiality statement.
Any doctors who are unsure
how to transmit confidential
patient information in a
responsible way are urged
to refer to current Irish data
protection legislation.
n www.medicalcouncil.ie
n www.dataprotection.ie
New breast cancer guidelines for GPs
The HSE has launched new
guidelines to help GPs diagnose
breast cancer. The guidelines,
which were developed in
association with the National
Cancer Care Programme
(NCCP), specifically define how
to differentiate between patients
New registration rules
There are now four divisions of
the Irish Medical Register – the
General, Specialist, Trainee
Specialist and Visiting EEA
Practitioners divisions. In order
to practise in Ireland you must
be registered in one of these
divisions.
If you are a trainee, you should
be very aware of a new specific
who need urgent, early or routine
referral for specialist attention.
It states:
n Patients with breast cancer
symptoms should be referred
to a national symptomatic
breast clinic
rule regarding Trainee Specialist
Registration – ie, those practising
in an individually numbered,
identifiable post which has been
approved for that purpose.
The effect of the new
registration restricts the
personal practice of doctors on
the Trainee Specialist division
to the clinical site of the training
n All patients should be told
how to conduct self-checks
to identify breast cancer
symptoms early
n Breast cysts or biopsy
breast lumps should not be
aspirated in GP practices.
n www.irishmedicalnews.ie
are registered in the general
division or the specialist
division of the Specialist
Register are able to undertake
locum work.
n www.medicalcouncil.ie
post, and you are not permitted
to practise medicine outside
that particular training post.
Specifically, such trainees are
unable to engage in any other
unrelated work, including
locums, and should not
prescribe drugs to patients
other than in connection with
their training posts.
NEWS IN BRIEF
MPS launches guide
to consent
MPS has produced a new
guide for members on issues
surrounding consent.
The booklet has been
written as a guide to the
ethical and legal principles
that should be applied, both
in straightforward and more
challenging circumstances.
New GP contract
talks planned for 2010
The Irish Medical
Organisation (IMO) is
expected to negotiate a
new contract for its GP
members in 2010, following
an amendment to the
Competition Act.
The Department of Health
and Children (DoHC) says that
a contractual framework was
drawn up and presented to
the government in July, and
then passed to the Office of
the Parliamentary Counsel. A
draft version is expected to be
submitted to the Oireachtas
for debate later this year, with
action expected to be taken
in 2010.
n www.irishmedicalnews.ie
No fee cuts for
social welfare
assessments
The Department of Social
and Family Affairs (DSFA)
has announced that doctors
will not be subject to a
reduction in fees for carrying
out assessments on social
welfare patients.
Instead, the DSFA has
agreed to increase the amount
that doctors receive for
carrying out the assessments,
which include conducting
disability assessments and
producing medical certificates
and reports.
n www.irishmedicalnews.ie
6
ireland casebook vol. 17 no. 3, SEPTEMBER 2009
www.medicalprotection.org

IRELAND ARTICLE
Small changes, big results
Gareth Gillespie and Julie Wilson look
at how MPS’s clinical risk assessments
can transform practice systems and
the approach to patient safety
Dr James Reason, a renowned
cognitive psychologist, began
to explore human error after
he became intrigued about our
absent-mindedness. He used
the “Swiss cheese” model to
explain human fallibility; ie, a
trajectory of an accident.
Our systems may be full of holes
like a Swiss cheese. When a
few of these holes “line up”, our
systems can let us down and an
adverse incident can arise. What
we need to do is close as many
holes as possible; ie, have strong
systems in place. 1
So what has all this to do with
your work? General Practice
is an area of risk. It is busy,
demanding, stressful, diverse
and can involve working long
hours. You may worry, in
today’s compensation culture,
about getting sued. But
perhaps you could ask how do I
safeguard my patients, how can
I prevent errors occurring?
Patient safety is intrinsic to MPS
and one of our aims is to work
with healthcare professionals
through education and risk
management to prevent
avoidable harm to patients.
To meet this aim we have
developed a Clinical Risk Self
Assessment (CRSA) for general
practice. A CRSA is a systematic
approach to identifying risks and
developing practical solutions to
ensure quality of practice, and
preventing harm to patients,
ie, making the systems in your
practice safer.
Undertaking clinical risk
management is not difficult.
In fact, it is common sense
and involves everyone in the
practice including the cleaner,
maintenance personnel,
administration staff, nurses and
doctors.
So what risks lie in
general practice?
From MPS’s experience of
CRSAs across the UK and
Ireland, below are some of the
common areas of risks seen in
general practice.
Confidentiality
Due to the open-plan design of
many reception areas, a breach
of confidentiality is possible.
What human factors can
lead to mistakes?
n Fatigue (sleep deprivation)
n Hunger – long lapses
between food/drink
n Lack of concentration
n Interruptions
n Distractions
n Lack of training
n Lack of information
n Unfamiliarity with place of
work (different room, new
ward, etc)
n Other – illness, under
influence of drugs, alcohol,
etc
Although difficult to tackle, there
are simple measures that can
be put in place such as:
n A touch-screen booking
system will reduce the number
of patients at reception, or
use a line or barrier to prevent
patients queuing directly
beside the reception desk
n Relocating the telephones
at the front desk, so that all
incoming calls are taken away
from the reception desk
n Installing computer privacy
screens, so that information
can only be viewed directly in
front of the screen
n Training reception staff on the
importance of confidentiality,
including keeping voices
down, identifying a patient
using the date of birth and
address, and not repeating
the patient’s name.
Excessive noise from reception
areas and other consulting
rooms can lead to problems
with confidentiality, and is
generally an undesirable
distraction. Simple soundproofing
and draught excluders
can deal with this problem and
is not particularly expensive.
The Medical Council is clear that
“the doctor must not disclose
information to any person without
the consent of the patient”. 2 It
is important that members of
staff are trained in confidentiality
issues and that the message is
regularly reinforced.
Prescribing
Medication errors take up about
20% of all errors occurring in
general practice and many
of these are preventable. 3
Common specific examples
include wrong dosage,
inappropriate medication and
failure to monitor for toxicity and
side effects.
It is essential to discuss and
draw up a comprehensive
repeat prescribing protocol
that formalises all the good
prescribing systems that take
place at the practice. Staff need
to be trained in the procedure
and have access to the protocol.
In many practices this important
task is undertaken during the
day by a receptionist working
at the reception desk – ie, she
is multi-tasking. This procedure
should be undertaken with due
care and attention, ideally by
a designated person in a quiet
location, where full concentration
can be given to the task.
Ideally, best practice indicates
that medication added to the
prescription list should be done
by the GP. If medication is added
to the computer or changed by
administration staff, it must be
closely checked by the doctor
afterwards; considerable care
needs to be taken to ensure
that all the details are correct
and that it has been added to
the correct patient record. The
doctor has responsibility for the
prescriptions he/she signs. It is
also advised to have a system for
recalling patients on long-term
medication, eg, lithium, thyroxine
or anti-convulsants.
Following a CRSA, some
practices have implemented
a system whereby local
pharmacists were asked to keep
a note of every patient that they
had been forced to contact the
practice about, together with
the reason for the contact. This
8
ireland casebook vol. 17 no. 3, SEPTEMBER 2009
www.medicalprotection.org

IRELAND ARTICLE
has enabled practices to collate
all the mistakes common in
prescriptions.
Practice staff can then check
the resulting lists: among the
reasons for contact that have
been reported back to MPS
are medicinal omissions, and
the inclusion of discontinued
medicines and similar-sounding
– but incorrect – medicines.
Test results
Sixty-three per cent of MPS
claims in general practice are
related to failure to diagnose 3 and
many of these can be attributed
to system error; for example, test
result abnormal but not acted on;
test result scanned into wrong
patient record; abnormal result
not communicated to the patient,
etc.
Simple measures can reduce
these risks:
n Practices should develop a
proactive system for dealing
with abnormal results, which
will minimise the risk of a test
result being overlooked. The
practice should make every
effort to contact the patient.
Record these attempts. Do
not file a result unless it has
been marked as having been
actioned.
n Consider undertaking an
audit of “ins and outs” of
patient samples to ensure
that all results have been
returned to the practice.
n Consider introducing either
a manual or computerised
tracking system to ensure that
patients are not lost in the
system and that test results
are adequately followed up.
Computer systems
Limitations of the practice
computer software system
have, historically, been
identified: in Ireland, it is advised
that the system be certified with
the GP Information Technology
Group (GPIT) which, among
other things, allows for an
efficient management of
results – including handling the
communication of results to
patients by phone, letter, SMS
text message or email.
Certification covers
requirements such as help desk
support, training, and functional
options for GP systems,
affecting consulting, prescribing
and vaccinating. GPIT strongly
advocates the use of certified
software. 4
Communications
Fundamental to patient care is
communication – between all
members of the practice team
and between the healthcare
team and the patient. Better
communication between staff
and patients is a priority for
improving patient safety. It
is important for all practice
What is an MPS CRSA?
Before the visit
A pre-visit questionnaire
should be completed, to
provide MPS with a snapshot
of your practice.
There will also be a staff
survey of patient safety
culture, the purpose of
which is to help identify the
importance attached to patient
safety in the practice.
The visit
A full day visit by a trained risk
assessment facilitator.
Confidential exploratory
discussions with key members
of staff from each discipline,
in order to gain an insight
into working practices and
perceived risks.
An educational session
staff to attend meetings to
ensure good communication
is maintained throughout the
practice. It is also helpful if,
wherever possible, disruptions
to meetings are minimised –
with interruptions only allowed
for emergencies.
Storage of drugs
Controlled drugs
If controlled drugs are stored
at the practice, these should
be stored in compliance with
the Misuse of Drugs Act (1977
& 1984) and Misuse of Drugs
Regulations (1993). Not all
practices we visited were
storing and recording these
drugs correctly, ie, keeping
them in a drawer in the
consulting room and not having
a controlled drugs register.
The controlled drugs should be:
n Stored under lock and key
in a safe/cabinet, preferably
fixed to a wall or the floor.
for all staff at the practice
providing an explanation of
risk management and its
importance, the purpose of
the visit and discussions of
risks that the practice think
could occur.
After the visit
An action plan is produced
by the MPS facilitator in the
form of a detailed report
containing summaries of
the main findings, along
with anonymised feedback
regarding the staff survey of
patient safety culture. The
action plan can be continually
used within team meetings
to review progress and keep
risk management firmly on
the agenda. After 12 months,
there is a follow-up patient
safety survey to qualitatively
measure improvement.
Ideally the safe/cabinet
should be within a cupboard
or some other position to
avoid easy detection.
n Stock should be kept to a
minimum and nothing should
be displayed outside to
indicate that controlled drugs
are kept within that receptacle.
A controlled drugs register (in
bound book form) must be
used for recording all incoming
and outgoing CDs. Each
product must be entered on
a separate page and running
balances maintained.
Storage of vaccines
It would be easy to make a
mistake and take the wrong
vaccine from the disorganised
refrigerator. The Royal College
of Physicians has published
guidelines on immunisation,
which includes storage of
vaccines: 5
n Ensure that the vaccine
refrigerator’s minimum and
maximum temperatures are
recorded daily; date and sign
that this check has been
undertaken.
n Organise the refrigerator to
ensure that different vaccines
can be easily seen. You may
wish to consider purchasing a
second vaccine refrigerator to
separate childhood and travel
vaccines, thus making it easier
to organise the refrigerator.
n Consider displaying the
current childhood vaccination
schedule on the refrigerator
door as an aide memoir for all
clinicians.
n Ensure that all clinicians
undertaking childhood
vaccinations are fully
conversant with the current
programme.
Decontamination
Some practices that we have
visited wrapped instruments
that require sterilisation in
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9

IRELAND ARTICLE
pouches and placed them in
the autoclave. It is essential that
if you are using this method of
sterilisation that you check that
your autoclave is suitable for
wrapped instruments; please
note that a non-porous load
autoclave is not suitable for
wrapped instruments. For further
advice on decontamination,
follow agreed existing protocols
and guidelines.
© Rick Walker
Incidents that have been reported
may need further analysis and
systematic investigation, and
these can be discussed at a
significant event meeting.
It is imperative that all the
practice staff should be made
aware of the purpose of the
practice incident reporting
system and how it works.
Therefore, training is essential.
Chaperones
Do you have a chaperone
policy at the practice? If so, do
all clinical staff adhere to this
policy? The Medical Council
states in A Guide to Ethical
Conduct and Behaviour:
“Any intimate examination
should be accompanied by
an explanation. The patient,
irrespective of age or gender,
should be offered a chaperone.”
There are two considerations
involved in having a chaperone
to assist during intimate
examinations; namely the
comfort of the patient and
the protection of the doctor
or nurse from allegations of
impropriety. Female doctors
should follow the guidance in
the same way as male doctors.
A useful checklist for a
consultation involving an
intimate examination is:
n Establish there is a need for
an intimate examination and
discuss this with the patient.
n Explain to the patient why
an examination is necessary
and give them an opportunity
to ask questions, ie, obtain
consent. Record this consent.
n Consider routinely using
a chaperone or invite the
patient to have a family
member or friend present.
If the patient does not want
a chaperone, record in the
patient’s notes that the offer
was made and declined.
n Give the patient privacy to
undress and dress. Use
paper drapes where possible
to maintain dignity.
n Explain what you are
doing at each stage of the
examination, the outcome
when it is complete and what
you propose to do next. Keep
the discussion relevant and
avoid personal comments.
n Record the identity of the
chaperone in the patient’s
notes.
n Record any other relevant
issues or concerns immediately
after the consultation.
n In addition, keep the presence
of the chaperone to the
minimum necessary. There is
no need for them to be present
for any subsequent discussion
of the patient’s condition or
treatment, for example.
Patient safety incident
reporting
An incident reporting system
that encourages all staff to
report incidents that occur is
a good learning tool. A “being
open” stance is helpful and key
to making sure everyone can
learn from such incidents, as
is adopting a non-judgmental
attitude.
The Department of Health and
Children’s Building a Culture of
Patient Safety 6 provides details
on incident reporting systems.
Please see Chapter 7.4, page
164.
Reporting when things go wrong
is essential, as is looking at the
underlying causes of patient
safety incidents and learning
how to prevent them from
happening again. When things
go wrong it is easy to apportion
blame to an individual (human
error), but closer analysis of
the incident may reveal that
there could be many underlying
causes which contribute to the
incident. These causes extend
beyond the individual staff
member involved.
For example, incidents may
occur because:
n The staff member has not
had sufficient training.
n The policy/procedure that they
are working to is not robust
or is outdated and does not
reflect current practice.
Conclusion
Managing risk is a continuous
process of evaluation, action
and re-evaluation, rather than
a one-off event. Undertaking a
risk assessment is an important
step in identifying areas where
you are performing well and
areas where changes would be
beneficial.
The first step in making any
kind of change is to be willing
to look inwards and admit to
your existing shortcomings, but
always with a positive outlook:
rather than focus on criticism, it
is more beneficial to believe that
one can always be better.
It’s not a matter of worrying
about being sued. Putting
patient safety at the centre of
everything gives you the peace
of mind that the systems were in
place, should the worst happen.
REFERENCES
1. Reason J, Human Error: Models and
Management, BMJ 320:768-770 (2000)
2. The Medical Council Ireland, A Guide
to Ethical Conduct and Behaviour, 6th
edition (2004)
3. Silk N, What Went Wrong in 1,000
Negligence Claims, Health Care Risk
Report (2000)
4. www.icgp.ie/go/in_the_practice/
information_technology/software_
companies
5. Royal College of Physicians,
Immunisation Guidelines for Ireland
(2008), available from: www.dohc.
ie/publications/pdf/immunisation_
guidelines.pdf?direct=1
6. The Department of Health and
Children, Building a Culture of Patient
Safety (2008), available from: www.dohc.
ie/publications/pdf/en_patientsafety.
pdf?direct=1
10
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ARTICLE
Cauda equina syndrome
Consultant orthopaedic surgeons Alan Gardner and
Tim Morley provide the medicolegal background and a
review of the clinical literature
Medicolegal
considerations
Cauda equina syndrome
(CES) is a rare condition
with a disproportionately
high medicolegal profile and
figures significantly in terms of
medicolegal costs. During the
five years between 1 January
2003 and 31 December 2007,
MPS was notified of 63 likely
claims worldwide relating to
CES, of which 46 were in
the UK. Of the 20 concluded
cases, damages were paid in
55%, with an average payment
of £117,331 per case. This
represents a total payout
of £1,290,641 over the five
years (£258,128 per annum),
with only one third of the
cases concluded. The highest
settlement was £584,000.
Forty-three of the 63 cases
related to general practice and
11 to orthopaedic surgery,
with two each to radiology and
neurosurgery and the remaining
five to other specialties.
Such substantial costs are
a reflection of the damaging
and distressing nature of the
condition. The statistics also
indicate the vital importance
of getting the diagnosis right
and the potential difficulties
surrounding surgery.
Although there are a number
of potential causes, CES
occurs most frequently
following a large lower lumbar
disc herniation, prolapse or
sequestration. This article looks
at the problem of CES resulting
from compression by lumbar
disc herniation, prolapse or
sequestration, about which
most has been written.
Diagnosis
CES is usually characterised by
the following so-called “red flag”
symptoms:
n Severe low back pain (LBP)
n Sciatica – often bilateral
but sometimes absent –
especially at L5/S1 with an
inferior sequestration
n Saddle and genital sensory
deficit
n Bladder, bowel and sexual
dysfunction.
Three types of cauda equina
syndrome have been identified:
n Rapid onset without a
previous history of back
problems.
n Acute bladder dysfunction
with a history of low back
pain and sciatica.
n Chronic backache and
sciatica with gradually
progressing CES. 1
Within these groups, CES may
be complete or incomplete and
its onset may be either acute
within hours or gradual over
weeks or months. 2
CES-incomplete (CES-I)
and CES-retention
(complete) (CES-R)
Although the above
description is clinically
© istockphoto.com
useful, in medicolegal terms
the important distinction is
whether, at any given time,
CES is complete or incomplete
in relation to urinary function
and perineal sensation. These
are both relatively easy to
assess – urinary dysfunction
is often the most distressing
sequel of CES.
When the syndrome is
incomplete (CES-I), the patient
has urinary difficulties of
neurogenic origin, including
altered urinary sensation, loss of
desire to void, poor stream and
the need to strain. Saddle and
genital sensory deficit is often
unilateral or partial.
The complete syndrome
(CES-R) is characterised by
painless urinary retention and
overflow incontinence. There is
usually extensive or complete
saddle and genital sensory
deficit.
The outcome for patients with
CES-I at the time of surgery is
generally favourable, whereas
those who have deteriorated
to CES-R by the time the
compression is relieved
have a poorer prognosis –
although around 70% have a
socially acceptable long-term
outcome. 3
Low back pain and sciatica
are of course common, but
bilateral neurogenic sciatica
should always ring alarm bells.
Its occurrence with any “red
flag” symptoms must trigger
immediate action, generally
involving emergency referral to
an A&E department with ready
access to a Spinal Surgery Unit
– preferably accompanied by
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11

ARTICLE
an explanatory telephone call to
reduce delays. The diagnosis
is confirmed by prompt MRI
scanning. 4
Essential questions to
ask:
n History of back pain. Put
your finger(s) on the worst
place.
n Where is your leg pain?
n When did you last pass
urine/open your bowels?
n Does your backside/
genital area feel normal?
n Can you feel whether your
bladder is full?
n Can you tighten your
anus?
n Have you had any
dribbling/leakage?
Background
CES is a significant indication
for surgery in around 2-3% of
all operations for lumbar disc
prolapse, with an incidence in
the population thought to be
between 1 in 33,000 to 1 in
100,000. 3,5,6 It generally requires
urgent surgical treatment, so
it is difficult to carry out highquality
prospective studies with
statistical power sufficient to
establish conclusions concerning
the principal contentious issues.
These are:
n The significance of delays
in diagnosis and referral to
hospital
n The risks and benefits of
emergency versus urgent
surgery
n The significance of surgical
delay beyond 24 and 48 hours
n The prognostic significance of
complete versus incomplete
sphincter involvement and
complete versus incomplete
sensory deficit
n The prognostic significance
of unilateral and bilateral leg
signs
n The medicolegal implications
of the above.
The most regrettable and
life-affecting consequence of
CE compression is bladder
dysfunction. The terms CESincomplete
(CES-I) and CESretention
(CES-R) are useful and
usually identifiable reference
points with some relevance to
the timing of surgery and clinical
outcome.
CES may develop relatively
acutely, usually with severe
low back pain and often with
complete anal and bladder
motor and sensory loss and
usually, but not always, with
motor and sensory deficits in the
lower limbs, all within 24 hours
(CES-R, Tandon and Sankaran
Group 1). 1 At the other end of
the spectrum, low back pain
may be mild, with gradually
developing or intermittent
sciatica over weeks or months in
one or both legs, and incomplete
or intermittent deficits of bowel
and bladder function (CES-I,
Tandon and Sankaran Group 3);
there may be a relatively modest
central disc prolapse causing
compression because of a
degree of stenosis of the spinal
canal.
Questions arise as to what
extent these variations in time
and severity of compression
are of prognostic significance.
First, in relation to the delicate
unmyelinated preganglionic
fibres of the cauda equina in or
near the midline, accompanied
by the pudendal nerves, and
secondly, for the more robust
sciatic nerve roots laterally at
the exit foramina in which the
sensory nerves are smaller and
more sensitive to compression
than the motor nerves. 7 The
answer is unclear, with conflicting
conclusions in the literature, and
especially in individual cases
where vital reference data may
be missing from the record. One
can only advise that, the longer
compression continues, the more
likely is long-term neurological
damage initially to the autonomic,
and subsequently to the somatic,
components of the cauda
equina.
A further factor may be at work,
and that is the possibility of
chemical interference with the
function of nerves in contact
with the irritating components
in prolapsed nuclear disc
material. 8 Involved nerve roots
are sometimes noted to be
grossly swollen and inflamed
at surgery. It may be that nerve
recovery, after three days or
more have passed before
surgical decompression, may
at least be partly explained
by resolution of this chemical
effect. In other situations,
such as the use or misuse
of a tourniquet, the effect of
nerve compression for more
than four to six hours is usually
considered to be irreversible.
On the other hand, it may
be that the clinical diagnosis
of CES-R, with its less good
prognosis – often on the basis
of scanty information – may
be overly pessimistic in some
cases when they are in fact still
CES-I at the time of surgery.
The traditional view was that
“early operation is an essential
prerequisite for an improved
prognosis”. 9 This seems logical
and intuitive, if somewhat
simplistic, as examination of
the available evidence provides
inconsistent support for this
point of view. It begs the
questions: how early is early?
And when does the clock start
ticking? Is it at the onset of CES
symptoms or from the loss of
bladder control, or from the
time of admission to hospital
or surgical unit? Also, what
symptomatic characteristics,
if any, are good indicators of
prognosis? Is it the presence
or absence of perineal sensory
loss or unilateral or bilateral
sciatica or motor weakness in
the lower limbs, or the presence
or absence of bladder and/or
anal motor or sensory function?
Finally, from a medicolegal
perspective, at what stage, if at
all, was the situation retrievable
by surgical decompression? If
there was demonstrable delay,
what difference did this make
and what would have been the
outcome if that delay had not
occurred? As involved clinicians,
or expert witnesses, we have
not only to admit our uncertainty,
where necessary, but also
not stray from the validated
behaviour patterns of this
complex and variable condition.
The literature
In reviewing the literature, we
may start with the meta-analysis
by Ahn et al which indicates:
“There was a significant
advantage to treating patients
within 48 hours, versus more
than 48 hours after the onset
of cauda equina syndrome.
A significant improvement in
sensory and motor deficits
as well as urinary and rectal
function occurred in patients
who underwent decompression
within 48 hours versus after 48
hours.” 10 They also stated that
“no significant improvement in
surgical outcome was identified
with interventions less than 24
hours from the onset of cauda
equina syndrome compared
with patients treated within
24-48 hours”.
However, Kohles et al (2004)
critically reassessed the Ahn
paper and concluded that,
although an advantage existed
in treating patients within 48
hours, there was further benefit
in treating patients within 24.
They make the logical point that
the earlier the surgery, including
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ireland casebook vol. 17 no. 3, SEPTEMBER 2009
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ARTICLE
within 24 hours, the better the
outcome. 11
Gleave and Macfarlane
(1990) reported that retention
developing less than 48 hours
after an acute prolapse was
associated with a poorer
prognosis. 3 They believe that
in the majority of such cases
“the die is cast at the time of
the prolapse”, depending on
the rapidity of its development
and the severity of the nerve
compression and that “there
is no evidence to support the
view that emergency surgery
influences the degree of
recovery”. Indeed, emergency
surgery in the middle of the
night by inexperienced staff
may not be in the patient’s
best interest. Decompression
of a large midline disc prolapse
or sequestration is often a
demanding procedure. An
appropriately experienced
surgeon is essential.
They conclude, however, that
a diagnosis of incomplete CES
requires urgent surgery in order
to prevent progression of the
condition.
In a review of the literature in
2002, they go on to highlight
the following points: 3
n Patients with incomplete
CES are best treated by
early surgery and tend to
show a favourable outcome.
However, around 70% of their
CES-retention patients had
a good result from surgery
carried out a mean of 3.7
days after onset; a similar
figure to Shapiro’s group
who were operated upon
within 48 hours. 12 They agree
that incomplete CES is best
treated by early surgery.
n Urodynamic studies can
show a serious disturbance
of bladder function after
CE compression and yet
the patient may have no
symptoms at all. 12
n Recovery of bladder and
sexual function may continue
for a number of years after
injury. 13,14 This is unlikely to be
due to neural regeneration,
but reflects the patient’s ability
to develop compensatory
strategies for coping with
bladder sphincter denervation.
Length of follow-up is therefore
an important variable.
n Recovery of sexual function
appears to mirror sphincter
outcome.
n Surgical exposure should
generally be via full
laminectomy rather than
microdiscectomy. Permanent
damage can result from
excessive manipulation of
the dura and occasionally
transthecal excision may be
necessary.
n Nerve ischaemia for more
than around four hours is
irreversible. “That window
of opportunity is manifestly
impossible to achieve in the
clinical situation; it must be
concluded that the outcome
of CES-R has already been
decided by the time the patient
is admitted to hospital.”
Gleave and Macfarlane
conclude that whilst urgent
surgery remains indicated for
patients with an incomplete
lesion, to prevent them from
progressing to complete CES,
examination of the literature
does not support a role for
emergency surgery to treat a
condition which is complete
at the time of presentation to
hospital.
Conclusion
CES occupies a prominent
position in the medicolegal
field, partly perhaps through
lack of awareness and urgency
in its management, and partly
because of the devastating
consequences of inadequate
management which may lead to
bowel, bladder, sexual and lower
limb dysfunction. However, it is
now established that, in around
half of cases, the die is cast
within the first four-six hours of
a severe central disc prolapse
resulting in CES-R. This is a very
small window of opportunity
in which to achieve referral
to an appropriate hospital,
confirmation of diagnosis
by MRI scan and surgical
decompression. It follows that
minor delays are probably not
significantly related to causation
in these cases.
Nevertheless, prompt diagnosis
and investigation, followed by
a full explanation and consent
procedure before timely and
skilful surgery and rehabilitation,
are the essentials of best practice
in the treatment of this rare, but
often very damaging, condition.
It is a tragedy, sometimes
avoidable, if an incomplete
syndrome becomes complete
while under medical supervision.
Major causes of delay
and dissatisfaction in
practice are:
n Patients, often previously
asymptomatic, who delay
seeking advice.
n GPs not recognising the
urgency of “red flag”
symptoms. (See the boxed
text on page 14)
n Junior A&E staff missing
the diagnosis and not
calling a senior.
n Hospital delays in
admission to a surgical
unit and arranging
MRI and surgery at an
appropriate time by a
suitably experienced
surgical team.
n Failure to warn of persistent
neurological symptoms in
the preoperative consent
procedure.
n Deficiencies in aftercare
and multi-disciplinary
rehabilitation.
(See also the case report on
CES on page 18)
© medical RF.com/sciencephotolibrary
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13

ARTICLE
Red Flag Symptoms of Cauda Equina Syndrome – (CES)
Typically from a Central Prolapsed Intervertebral Disc Protrusion
n Usually bilateral neurogenic sciatica & LBP
n Perineal / genital numbness
n Has not passed urine (HNPU) since > approx 6-8hrs
Triage
CES-Incomplete – Emergency management!
Ideally surgery within 12 hours of diagnosis – Good
prognosis.
Symptoms
n Sciatica may be unilateral, bilateral or absent (L5/S1
prolapse) – if present, is it increasing in intensity or becoming
bilateral?
n Perineal numbness – may be unilateral and patchy,
becoming bilateral and spreading.
n Neurogenic urinary dysfunction – HNPU > approx 6hrs loss
of desire to void, poor stream, strain to micturate, sensation
of full bladder.
Physical signs
n Sciatica – check for neurological deficit in legs – SLR,
reflexes, power and sensation. May be deteriorating and
becoming bilateral.
n Perineal numbness – usually incomplete – check light touch
and pin-prick – always test for both.
n Neurogenic bladder and bowel dysfunction – check anal
sphincter tone (DRE) and “wink” reflex.
CES-Retention – Urgent management!
Ideally surgery within 24 hours of diagnosis – Less good
prognosis.
Symptoms
n Sciatica – as for CES-I – lumbar and sacral nerve roots
may suffer progressive damage resulting in long-term
neuropathic leg pain/numbness.
n Perineal numbness – as for CES-I but likely to be
widespread and complete with diminishing discomfort.
n Neurogenic urinary dysfunction – HNPU > approx 8hrs,
painless urinary retention, overflow incontinence, no bladder
sensation or control, faecal incontinence.
Physical signs
n Sciatica – as for CES-I. May be more severe and bilateral
with increased neurological deficit. May be absent or mild
with L5/S1 prolapse.
n Perineal numbness – complete sensory deficit. Check light
touch and pin-prick.
n Neurogenic bladder and bowel dysfunction – painless full
bladder, no anal sphincter function.
ACTION
Immediately seek senior advice with a view to contacting a Spinal Surgery Team and
arranging emergency MRI with transfer to a Spinal Surgery Unit if not available on site.
Delay may cause further neurological damage!
References
1. Tandon PN and Sankaran B, Cauda
equina syndrome due to lumbar disc
prolapse, Indian J. Orthop 1:112-119
(1967).
2. Gleave JRW and Macfarlane R,
Prognosis for recovery of bladder
function following lumbar central disc
prolapse, Brit J. Neurosurg 4:205-210
(1990).
3. Gleave JRW and Macfarlane R,
Cauda equina syndrome: what is the
relationship between timing of surgery
and outcome? Brit J. Neurosurg
16(4):325-328 (2002).
4. Coscia M, et al, Acute cauda equina
syndrome: diagnostic advantage of MRI,
Spine 1994; 19:475-478.
5. O’Connell JEA, The indications for
and results of the excision of lumbar
intervertebral disc protrusions; a review
of 500 cases, Ann. R.Coll. Surg. Engl
6:403-412 (1950).
6. Anthony S, Cauda equina syndrome,
MPS Casebook Spring 2003; 20: 9-13.
7. Olmarker K, The spinal nerve roots,
Acta. Orth. Scand Suppl 242:1-27
(1991).
8. Rydevik BL, Brown M, Lundborg G:
Pathoanatomy and pathophysiology of
spinal nerve root compression, Spine
1984 Jan-Feb; 9(1): 7-15.
9. Shephard RH, Diagnosis and
prognosis of cauda equina syndrome
produced by protrusion of lumbar disc,
Brit Med J 2:1434-39 (1959).
10. Ahn UM, et al, Cauda equina
syndrome secondary to lumbar disc
herniation – a meta-analysis of surgical
outcomes, Spine 25; 12:1515-1522
(2000).
11. Kohles SS, et al, Time-dependent
surgical outcomes following cauda
By Alan Gardner, Edward Gardner, Tim Morley 2009
equina syndrome diagnosis – Comments
on a meta-analysis, Spine 29; 11:1281-
1287 (2004).
12. Shapiro S, Cauda equina syndrome
secondary to lumbar disc herniation,
Neurosurgery 1993; 8: 317-322 (1993).
13. Dinning TAR and Schaeffer HR,
Discogenic compression of the cauda
equina: a surgical emergency, Aus. N.Z.
J. Surg 63: 927-934 (1993).
14. Chang HS, et al, Lumbar herniated
disc presenting with cauda equina
syndrome: Long-term follow-up of 4
cases, Surg. Neurol 53:100-5 (2000).
14
ireland casebook vol. 17 no. 3, SEPTEMBER 2009
www.medicalprotection.org

CASE REPORT
INTRODUCTION
On the case
Head of Medical Services (London),
Alison Metcalfe, introduces this issue’s
round-up of case reports, which
feature a number of different aspects
of communication
it difficult to communicate
verbally. This may be due
to a physical impairment,
language problems or simply
when a patient is faced with
discussing a condition which
may be embarrassing to
them. It is important to equip
yourself for dealing with such
tricky situations, which may
involve adapting how you
communicate to help you
overcome those issues.
What’s it worth?
Since precise settlement figures
can be affected by issues that
are not directly relevant to the
learning points of the case
(such as the claimant’s job or
the number of children they
have) this figure can sometimes
be misleading. For case reports
in Casebook, we simply give
a broad indication of the
settlement figure, based on the
following scale:
Dr Alison Metcalfe
Your communication with, or
about, a patient will dictate the
overall success of the clinical
encounter for both you and the
patient. It will determine whether
the necessary rapport with a
patient is established; whether
there is proper continuity of care;
whether the correct diagnosis
is made; whether a problem,
if it arises, can be successfully
resolved. Communication can
take a number of forms, even
within the labels of written and
spoken communication. This
issue’s set of cases looks at
examples of both the good
and the bad and the potential
outcomes that follow.
The case on page 16
demonstrates how important
clinical examination is when
faced with a patient who finds
Two cases in this issue highlight
the limitations of verbal
communication when you are
not face-to-face with a patient
– specifically during telephone
consultations. Not only do
such consultations preclude a
physical examination, but they
deprive you of the visual clues
which are so vital in making
an accurate diagnosis. It is
important to be aware of these
limitations and to exercise
your judgment as to what you
are able to accurately assess
over the phone and whether
you have sufficient information
to make a reasonable clinical
decision. It is also important
to ensure that you make
provision for appropriate
safety-netting when faced with
such situations; for instance,
what action a patient should
take in the face of worsening
symptoms.
Another theme in this series
of case reports is to beware
of the potentially serious
alternative possible diagnoses
when confronted with common
presentations, such as earache,
headaches and back pain.
Being open to the possibilities
and asking the right questions
in such situations is important in
avoiding unfortunate outcomes.
l High €1,500,000+
l Substantial
€150,000+
l Moderate €15,000+
l Low €1,500+
l Negligible

Case report
diagnosis
General practice
Dysphasia – dysuria – disaster
Mr W, a 70-year-old retired
shoe mender, went to his
GP surgery because he was
experiencing difficulty passing
urine. He had previously
suffered a stroke leaving him
with marked speech difficulty,
so verbal communication was
not easy. His main complaints
were of dysuria, bouts of urinary
incontinence and a split urinary
stream. His symptoms had come
on gradually and worsened over
the course of a year.
© David Gold/istockphoto.com
He saw four different doctors
at the practice over a period of
three months. He was treated
with antibiotics for a presumed
urinary tract infection on four
occasions. This was on the
basis of urine dipstick tests
which were positive for nitrites,
leucocytes, blood and protein.
No definitive infecting organism
was ever cultured from MSU
samples.
At no point during
his attendance
with this problem
is there any record
of a physical
examination
On one occasion he mentioned
that the tip of his penis had
been sore, and this led one of
the doctors to make a nonurgent
referral to a urology
clinic. At no point during his
attendance with this problem is
there any record of a physical
examination.
About four months after his last
attendance at the surgery, Mr
W attended the urology clinic.
Examination of the penis showed
an ulcerated, erythematous mass
close to the external urethral
meatus which was causing
partial obstruction and division of
the urinary stream.
Biopsy of the lesion showed it
to be an invasive, moderately
differentiated keratinising
squamous carcinoma. Mr W
underwent partial penectomy.
However, metastatic spread
had already occurred and he
died two years after his initial
diagnosis.
Mr W’s wife sued the doctors
at his GP practice, alleging
negligence in their handling of
his case, leading to a delay in
diagnosis which contributed to
Mr W’s death.
Expert opinion
The main failing in this case
was considered to be the
omission of examination of Mr
W’s external genitalia, given
that he had a persistent split
urinary stream and at one
point complained of penile
soreness. Blindly continuing to
treat for urinary tract infection
without any confirmatory
evidence was felt to be poor
Learning points
n When obtaining a detailed
history is made difficult
by communication
issues, detailed physical
examination and
appropriate investigation is
the best route to a correct
diagnosis.
n Treating a man of this age
with such symptoms it would
be prudent to examine the
patient’s prostate.
n Patients may be reluctant
to mention that they have
problems “down below”
so have a low threshold for
directly asking about penile
lesions and examining the
external genitalia, where
there are distal urinary
tract symptoms. It may
be that the use of slang
or euphemisms may aid
communication.
n Any complaint of itching,
burning sensation, soreness
or bleeding affecting the
practice. The claim was
settled for a moderate sum.
SK
glans or prepuce should
prompt consideration of
the diagnosis of carcinoma
of the penis, requiring
examination of the external
genitalia and inguinal lymph
fields.
n It is important to carry out
investigation before referral
and make use of available
outpatient investigations.
n Differential diagnosis of
penile lesions is fraught with
difficulty. Where there is
any doubt, you should refer
the patient to a urologist or
dermatologist for an opinion
and consideration of biopsy.
n Any lesion of the penis that
is potentially compatible with
penile carcinoma should
be referred urgently to a
urologist.
n Female practitioners
should offer to have a male
colleague examine the area
if embarrassment is a bar
to this.
16
ireland casebook vol. 17 no. 3, SEPTEMBER 2009
www.medicalprotection.org

Case report
Diagnosis; notekeeping
general practice/ENT
A long-lasting earache
Mr Y was a 25-year-old
engineer with Type 1 diabetes.
He attended his GP, Dr T,
regularly for check-ups and
on one occasion complained
of pain in his left ear. He could
not be sure how long it had
been there, but thought the
pain had come on about three
months earlier, following a visit
to the swimming pool with his
children. He had attributed it
to water getting trapped inside
his ear. Dr T examined him and
found the external auditory
meatus to be extremely
tender, but did not record
any exudate or erythema. He
noted that Mr Y’s pharynx was
normal, but there was mild
cervical lymphadenopathy and
accepted Mr Y’s assertion that
the swimming may have been
responsible. Dr T diagnosed
otitis externa and prescribed
topical antibiotic ear drops.
Over the next six weeks, Mr Y
visited the surgery and was seen
by both Dr T and his partner,
Dr L. Mr Y’s complaints ranged
from vague flu-like symptoms
and tiredness to neck pain,
continuing discomfort in his
left ear and a sore throat. Mr
Y told the doctors that his wife
thought he had lost weight. The
doctors noted the continuing
tenderness in the EAM, but little
sign of infection and checked
his weight, which appeared
stable. They did not arrange
any further investigations. The
diagnosis remained that of otitis
externa, and Dr T made a note
that Mr Y’s diabetes may have
been responsible for the poor
clinical improvement. Swabs
were taken, which did not show
any bacterial growth, and he
was prescribed a combination
of different topical and oral
antibiotics.
A month later Mr Y lost his
sense of smell and became
aware of hearing loss on the left
side. He presented at his local
A&E department and an urgent
ENT opinion was arranged.
After ENT assessment and
investigations, the final diagnosis
Learning points
n Once a diagnosis is made,
either by you or your
colleagues, it is not set in
stone. It can always be
challenged and alternatives
should be considered.
n Keep clear, accurate and
legible records. This is
particularly important where,
over a period of time,
several different doctors may
be involved in a patient’s
treatment.
n It is important to listen to
patients actively, but be
wary of false clues the
patient can give you. What
a patient thinks might be
was that of a low-grade
sinonasal adenocarcinoma in the
left nasopharynx and skull base.
The tumour was inoperable and
the patient received palliative
radiotherapy, which gave
substantial symptomatic relief,
but he died.
EXPERT OPINION
Expert opinion agreed that
although the final prognosis
responsible for their problem
can be helpful, but can
also be misleading and
lead to blinkered clinical
judgment. In the example
above, the patient believed
the visit to the swimming
pool was responsible
for his symptoms, and
to most of us this would
have made sense. In this
case, however, although
the symptoms began
afterwards, they were
unfortunately coincidental
and unrelated.
n When faced with vague
information or recollections
it is important to further
may have been the same,
the patient could have had
a superior quality of life in
the period before palliative
treatment commenced. They
found that an early referral
for investigation of recurrent
otitis externa would have been
standard practice. A claim
was settled for a moderate
sum.
GMcK
question the patient to try
to pin down the patient’s
history.
n Remember to be wary of
multiple pathologies.
n It is important to review a
patient’s previous medical
notes as they will often
present with symptoms
which can be relevant, but
may be spread out over
a number of visits and be
easily missed.
n Recurrent and persistent
symptoms that are resistant
to treatment should always
stimulate a review of the
diagnosis and the need for
further investigation.
© Carmen Martinez/istockphoto.com
www.medicalprotection.org ireland casebook vol. 17 no. 3, SEPTEMBER 2009
17

Case report
diagnosis
general practice
Don’t be blind to red flags
Mrs T, a 40-year-old school
secretary, had previously been
diagnosed with hypothyrodism
for which she was taking
levothyroxine. Her thyroid
function tests had been stable
for many years. In addition, she
had been prescribed citalopram
for depression since the loss
of her mother two years ago,
and omeprazole for gastrooesophageal
reflux.
She had been suffering from
back pain for a number of
months, which had become
progressively worse over a
couple of weeks. There was
no history of trauma although
she thought her worsening
pain may have been related
to moving her office furniture
around. She subsequently
consulted her GP, Dr D, who
diagnosed muscular spasm and
prescribed painkillers.
Mrs T promptly reattended the
surgery when her back pain
became significantly worse
following a severe coughing fit.
Dr D made a revised diagnosis
of sciatica and changed the
analgesia accordingly. His
notes, however, were limited
to “looks well; walked into
surgery”. Mrs T later alleged
that Dr D did not perform a
physical examination.
Over the next three days
Mrs T deteriorated, with
worsening discomfort in her
back to the extent that she
was unable to go to work
and needed her husband to
Learning points
n Chronic back pain is
common – cauda equina
is not. Therefore it is very
important to take a good
history to identify the “red
flags” symptoms, eg numb
buttock, urinary symptoms.
n Certain symptoms almost
always need physical
examination to avoid
missing clues.
n It is important to remember
the limitations of telephone
consultations. It is not
possible to make an accurate
© Monty Rakusen
help her shower and dress.
In addition to the severe back
pain, she began to experience
urinary symptoms and altered
sensation. In desperation, Mrs
T rang the surgery twice, over
a three-day period, to say
that she was having difficulty
passing water and that her
buttocks “felt funny”. She
discussed her situation with
Dr D, although documentation
on these conversations was
very limited and did not reflect
the development of these
red-flag symptoms, the full
severity of her symptoms or
the appropriate use of safetynetting.
Mrs T alleged that Dr
D advised her to increase the
amount of fluid she was taking
without offering to assess her in
a face-to-face consultation.
Her symptoms deteriorated
even further and five days after
the severe pain started Mrs T
attended the local out-of-hours
GP service. She was thoroughly
examined by the emergency
GP and was noticed to be in
urinary retention, her bladder
diagnosis in all circumstances
or to accurately assess signs
such as perineal numbness
over the phone. It is important
to get enough information
to exercise reasonable
judgment.
n Documenting everything,
including telephone
conversations, is always
the key to good practice,
and the foundation of your
defence.
n Please see the feature on
cauda equina syndrome on
page 11.
being palpable to the level of
the umbilicus. The out-of-hours
GP also found that Mrs T had
numbness of the perineum. As
a result, a diagnosis of cauda
equina syndrome was made and
she was referred urgently to the
orthopaedic registrar on call. An
MRI scan confirmed a prolapsed
inter-vertebral disc at L5/S1.
Given the acute neurological
presentation, she underwent an
emergency laminectomy and
excision of the prolapsed L5/
S1 disc.
Following the surgery, Mrs T
continued to experience a lack
of feeling in her perineal region.
She was deeply distressed
that the sensory loss caused
major sexual difficulties and this
had a profound impact on the
relationship with her husband.
Her depression deepened
and she felt inadequate as a
wife and a woman. In addition
to increasing the dose of
citalopram, she required intense
psychological support.
Mrs T was forced to selfcatheterise
several times a day,
which she found humiliating,
and suffered a number of
urinary tract infections.
Mrs T made a claim against Dr
D and experts on the matter
agreed that the care received
was substandard, that Dr D
had failed to examine or take
heed of worsening and serious
symptoms, and had cauda
equina been diagnosed sooner
the final outcome would have
been much more positive.
The claim was settled for a
substantial amount.
RT
18
ireland casebook vol. 17 no. 3, SEPTEMBER 2009
www.medicalprotection.org

Case report
handovers; Notekeeping
emergency medicine
Don’t drop the baton
Forty-five-year-old bus
driver Mr B attended A&E
following an episode of central
chest pain that resolved
spontaneously while he was
at work. The pain was severe
and radiating to his left arm
and it lasted about 15 minutes.
Mr B had no previous cardiac
history, but had several risk
factors: he was a heavy
smoker and somewhat
overweight. By the time he
arrived in the emergency
department, brought in by a
colleague from work, the pain
had subsided.
Junior doctor Dr O was
working a day shift at the
department on that day. He
took a comprehensive history
and performed a thorough
examination, which was normal.
Dr O looked carefully at the
ECG carried out on arrival and
documented that the ECG
appeared within normal limits.
Dr O arranged for Mr B to
have his troponin levels first
tested one and a half hours
later. He explained to Mr B the
importance of the blood tests
and suggested admission to
the A&E observation ward,
for repeated blood tests and
ECGs, but Mr B declined. Dr O
documented this.
Dr O’s shift finished before the
troponin test results were ready,
so he handed over the case
to another junior doctor, Dr W,
and asked her to make sure
the patient didn’t leave before
the test was proved to be
normal. However, Dr O did not
document his plan of action or
the name of the doctor he had
handed over to.
Two hours later, Dr W
discharged Mr B, and noted
“Non-specific chest pain.
Home”. She didn’t sign her
notes. Unfortunately, the
troponin levels were raised but
Dr W failed to check the test
results. Mr B suffered a further
episode of severe central chest
pain 24 hours later followed
closely by a fatal cardiac
arrest. The autopsy confirmed
the presence of an acute
myocardial infarction.
A claim was made alleging
substandard care by both
Dr O and Dr W. During the
course of the investigation, Dr
O insisted that he had handed
over to Dr W and specifically
suggested that the troponin
tests had to be checked, but
Dr W denied any knowledge
of the patient or the handover.
The documentation was very
limited, but some nursing notes
supported Dr O’s account of
the events. At the subsequent
Learning points
n Working shift patterns means
that careful handovers are
vital for patient safety. When
referring a patient or making
a handover, it is always
useful to document the time,
the name and the specialty
of the recipient doctor.
n Documenting a clear plan
of action, with specific
instructions, makes handing
over safer. It is important
to emphasise the need for
good communications within
teams, particularly with the
increasing use of flexible
working patterns.
n Leaving written records of
inquest, both doctors were
called to give evidence. Dr
O’s version of events was
accepted on the basis of
the nursing notes and some
of his documentation; his
management was considered
to be acceptable. However,
Dr W’s was considered
inappropriate. The hospital
what has been said to the
patient and relatives is also
good practice.
n The discharging doctor is
ultimately responsible for the
actual discharge of a patient
and its consequences. It is
important that care is taken
to ensure that discharge
of a patient is managed
appropriately and that the
patient is aware of the risks
and when to seek further
advice. If in doubt, deal with
the patient as if no other
doctor has seen him/her
before.
n Readable and clear notes will
lower the multiple dangers
settled the claim for a
substantial amount.
Further information
Discharge, referral and handover (General
Approach) Chapter 1, Oxford Handbook
of Emergency Medicine. 3rd Edition.
http://emedicine.medscape.com/
article/756979-overview
www.library.nhs.uk/emergency/
ViewResource.aspx?resID=266673
ML
of handing over and will
save time and effort to the
receiving doctor, particularly
in an environment such as
an emergency department
where time is precious. Avoid
using unusual abbreviations.
n Employers indemnity is
generally limited to claims
but does not usually extend
to representation for a
doctor for the consequences
of an adverse outcome
at an inquest. Dr O was
represented by MPS and
avoided criticism. Dr W was
not a member of a defence
organisation and was not
independently represented.
© Ron Sumners/istockphoto.com
www.medicalprotection.org ireland casebook vol. 17 no. 3, SEPTEMBER 2009
19

Case report
consent; NOTEKEEPING
General surgery
Consent? No sweat
© Gethin Lane/istockphoto.com
clothes several times a day.
This was extremely distressing
to Mr P. He deeply regretted
having the operation and
became profoundly depressed,
unable to work and socially
withdrawn.
Thirty-year-old Mr P had
suffered from facial and palmar
hyperhidrosis and blushing
since he was 14. Over the
years, he had tried various
over-the-counter remedies and
a period of psychotherapy with
no success. Although he had
learned to live with his condition
to some extent, he found it
socially inhibiting and believed
that it was preventing him from
progressing in his career as an
accountant. Having researched
hyperhidrosis on the internet,
Mr P was attracted to the
potentially permanent solution
offered by a sympathectomy
and asked his GP to refer him
to a suitably trained surgeon.
Three weeks later he saw Mr R,
a consultant surgeon, at his clinic
and requested an endoscopic
transthoracic sympathectomy,
telling Mr R that he had
conducted detailed research on
the internet and therefore had a
good understanding of what the
surgery entailed. Although Mr
P had clearly done his research
and had already concluded that
surgery was his best option,
Mr R nevertheless explained
the operation and its risks
and benefits to him in detail,
emphasising the well-known
side effect of compensatory
sweating. After discussing the
implications, Mr P was still intent
on undergoing the surgery,
indicating that he considered
compensatory sweating an
acceptable risk outweighed by
the benefits of the operation. Mr
R therefore agreed to perform
the surgery, but gave Mr P a
patient information leaflet to take
home with him, asking him to
read it and telephone him if he
had any further questions.
Mr P was admitted as a day
patient a month later for the
surgery. Mr R performed
endoscopic transthoracic
sympathectomies on both sides at
T2. The operation was uneventful
and Mr P was discharged home
later the same day.
The operation had the desired
effect of eliminating Mr P’s
problems with blushing
and his facial and palmar
hyperhidrosis, but it did result in
compensatory sweating on his
trunk and thighs. Unfortunately,
this failed to resolve itself and
increased in severity over the
next 18 months, to the point
where Mr P had to change his
Learning points
n The “well-informed patient”
is a common phenomenon
in countries with widespread
access to the internet.
Although these patients
may claim that they’ve
thoroughly researched
their treatment options and
thought it all through, their
doctors should still ensure
that patients are given all
the necessary information
Two years later, Mr R received
a letter from Mr P’s solicitors
requesting a copy of Mr P’s
medical records. He alerted
MPS to the possibility that a
claim would be made against
him and sent copies of the
records to the solicitors and
MPS. Fortunately, Mr R had
documented the substance
of Mr P’s pre-operative
consultation in the medical
records and, furthermore, had
followed up the consultation
with a letter to Mr P (with a
copy to his GP), in which he
reiterated the risks and benefits
of the operation. In our opinion,
Mr R was in a strong position
to defend an allegation of
negligence on the basis of
failure to secure adequate
consent for the operation. Mr
P’s solicitors evidently agreed
with our assessment as no
further action was taken.
SA
to make a properly informed
choice.
n Doctors might also consider
familiarising themselves with
sources that are available.
n Patients requesting specific
surgical procedures often
have unreasonably high
expectations about outcomes.
They may be so focused on
the perceived benefits of the
surgery that they don’t give
due regard to the risks.
20
ireland casebook vol. 17 no. 3, SEPTEMBER 2009
www.medicalprotection.org

Case report
consent; notekeeping
general Surgery
An unnecessary operation or two
© Daniel Fascia/istockphoto.com
operatively, but refused an NG
tube. Following discharge,
the patient complained of
epigastric pain and difficulty
in swallowing. A chest x-ray
revealed a large irreducible
hiatus hernia. Eventually,
Mrs R required further major
thoraco-abdominal surgery
for correction of a large hiatus
hernia and subsequently made
a complaint against Mr P.
should only be undertaken
by appropriately specialised
and experienced upper GI
surgeons. Although NG tubes
are not routinely required, all
upper GI procedures carry the
risk that they might be required.
Patients should be counselled
accordingly. The claim was
settled for a moderate sum.
SD
Mrs R, aged 40, was referred
to consultant general
surgeon, Mr P, complaining
of long-standing abdominal
pain, abdominal distension
and severe hiccups. Mr
P performed an upper
gastrointestinal endoscopy and
found a small sliding hiatus
hernia, but no oesophagitis.
Mrs R had already been
treated with proton pump
inhibitors by her GP, but had
experienced no improvement
in her symptoms. According
to the medical notes, Mrs R
was keen to consider surgical
treatment of her hiatus hernia.
Mr P subsequently undertook
a laparotomy and Nissen
fundoplication. A naso-gastric
(NG) tube was inserted at
the time of surgery, but this
was removed during the early
postoperative period as it was
not tolerated. Mrs R made an
otherwise uneventful recovery
and was discharged home
symptom-free.
A few months later Mrs R
experienced a recurrence of
her symptoms and saw Mr
P again. A barium swallow
demonstrated a recurrence
A naso-gastric (NG)
tube was inserted
at the time of
surgery, but this was
removed during the
early postoperative
period as it was not
tolerated
of the hiatus hernia. A new
operation was discussed.
Mrs R was agreeable,
but warned Mr P that she
did not want an NG tube
whatever the circumstances.
Mr P agreed, and a further
laparotomy and revision
Nissen fundoplication was
carried out. Mrs R experienced
abdominal distension post-
Expert opinion
Experts agreed that the first
operation was not indicated.
The patient’s symptoms
were not classical of gastrooesophageal
reflux (GORD)
and the finding of a small
hiatus hernia at the time of
endoscopy did not require
surgical intervention. The lack of
any response to protein pump
inhibitors and the absence of
any oesophagitis should have
prompted further investigation
in the form of oesophageal
manometry and 24-hour pH
monitoring.
Questions were also raised
about the reasons for
performing an open operation
(via a laparotomy) when
minimally invasive (laparoscopic)
Nissen fundoplication can be
carried out with decreased
morbidity, shorter hospital stay
and faster return to normal
activities. There was also
criticism regarding the consent
for both the first and second
operations, specifically relating
to the documentation of the
risks of surgery and the longterm
results. Experts were in
agreement that primary and
revisional anti-reflux surgery
are complex procedures which
Learning points
n Most common elective
procedures have a
requisite list of appropriate
pre-operative tests (often
supported by guidelines
from learned societies).
Preoperative oesophageal
physiology investigation
can confirm or refute
GORD and help identify
patients unsuitable for
surgery.
n It is imperative to ensure
that there are clear
indications for surgery
before proceeding.
n The options for
medical versus surgical
management of their
problem must be
discussed with patients.
n All discussions regarding
treatment options must
be recorded, including
any differences of opinion.
In this particular case, it
was unclear how much
pressure the patient had
put on the surgeon to
perform the first operation.
n If an operation may require
a particular intervention,
eg, an NG tube, it needs
to be made clear to
the patient that this is a
possibility.
www.medicalprotection.org ireland casebook vol. 17 no. 3, SEPTEMBER 2009
21

Case report
Diagnosis; Notekeeping
General Practice
Too little, too late
Dr M was working as the
“duty doctor” and, during her
afternoon surgery, she received
a phone call from Mrs B. Mrs B
was concerned regarding her
ten-month-old baby son who
had been screaming since early
that morning. She described
Baby B as hot, floppy and pale.
Dr M had a fully-booked
surgery and assured Mrs B
that she would visit Baby B as
soon as her surgery ended.
Dr M omitted to record any of
the conversation in Baby B’s
notes. Mrs B, when later asked,
said that Dr M did not ask any
further questions regarding the
clinical presentation of Baby
B. According to Mrs B, Dr M
advised her to give paracetamol
to her son in order to bring
down his temperature and
await review.
Dr M’s afternoon surgery
continued for a further three
hours, after which she drove
straight to Mrs B’s house.
On initial inspection, Dr M
became very concerned
and rang for an emergency
ambulance. Baby B was
floppy and unresponsive
and had a temperature of 40
degrees and a widespread
non-blanching rash. His skin
was mottled and he was
tachycardic. Dr M wrote a
letter to accompany Baby B
stating the likely diagnosis was
meningococcal septicaemia,
requiring urgent attention. Dr
M did not give any treatment
before Baby B was transferred
to hospital by ambulance.
On Baby B’s arrival in the
emergency department, the
diagnosis of meningococcal
septicaemia was confirmed and
urgent antibiotic treatment was
given. Following a long stay in
intensive care, Baby B survived,
but required the amputation of
three toes and four fingers.
Baby B’s parents were angry
with Dr M and commenced an
aggressive public campaign to
discredit her. They also began
legal proceedings against her.
The campaign against Dr M
involved the press and Dr M
gained much negative media
attention. MPS was able to
support Dr M in managing the
negative attention she received,
which was distressing and
impacted on her work and
home life significantly.
Expert Opinion
Medical experts agreed that the
long delay in starting treatment
significantly impaired the outcome
of Baby B. The symptoms that
Mrs B had described on the
telephone warranted immediate
medical review. Antibiotics
should have been administered
once the diagnosis of meningitis
was suspected.
ZS
© Vasiliy Koval/istockphoto.com
Learning points
n Documentation was
unacceptable in this case
– with no record of phone
conversations, difficulties arise
in assessing the decisionmaking
process of a doctor.
n Calls management in this
case was unacceptable and
practices must have agreed
procedures in place for dealing
with urgent calls. Significant
event analysis is an invaluable
test to see if the systems you
have in place are working.
n It is very difficult to assess
babies or children over the
phone. If there is concern or
uncertainty over the severity
of the child’s illness, it is
important to see the patient.
n A baby whose appearance is
described as floppy or pale
may be seriously ill.
n Criticisms of a doctor in the
media can be very damaging
to their reputation and very
difficult to deal with. Support
from organisations such as
MPS is often necessary.
n A doctor’s duty of
confidentiality persists even
in circumstances where
patients or relatives have
gone to the press.
n MPS has published A guide
for doctors on handling
the media, see www.
medicalprotection.org/uk/
education-and-publications/
media-handling-guide
n See also the Casebook
article “Don’t get caught
in the rash trap” www.
medicalprotection.org/uk/
casebook/february2006/
don't-get-caught-in-the-rashtrap
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ireland casebook vol. 17 no. 3, SEPTEMBER 2009
www.medicalprotection.org

Case report
Diagnosis; communication systems
General Practice
Difficulty getting through
© Monty Rakusen
quiet. She did not want to
play and was not interested
in eating or drinking. Her
mother was worried that her
shunt may be malfunctioning
again and so she rang the
surgery to speak to a doctor.
A receptionist dealt with the
call. She disregarded Z’s
mother’s concerns and told
her that “she had already
spoken with one of the
doctors yesterday”, adding
that all the clinics were full for
the next five days.
Z, a five-year-old girl, had been
born prematurely and developed
hydrocephalus following
intraventricular haemorrhages
that occurred in the neonatal
period. A ventriculo-peritoneal
shunt had been fitted to relieve
the hydrocephalus. She had
developed well and could walk
and play with her siblings. Over
the previous two years the shunt
had malfunctioned three times
and had needed revision and
replacement. Each of these
episodes had been linked with
viral infections.
about Z’s past medical history.
He advised regular paracetamol
and fluids.
Z was no better the following
day. She was vomiting more
frequently and was unusually
Z’s mother felt powerless but
tried to carry on with Dr X’s
advice giving paracetemol
and fluids. Later that day, Z
collapsed and was admitted
to hospital, where she suffered
a cardiac arrest and the
ventriculo-peritoneal shunt was
found to be malfunctioning.
Z recovered but was left with
long-term brain damage and
was unable to function in the
same way as she used to.
A claim was made against the
surgery.
AF
The mother
assumed Dr X
would have seen
Z’s records and
be aware of her
underlying condition
so did not mention
the hydrocephalus
or the shunt during
the telephone
consultation
Z’s mother had become
concerned, because Z had
vomited and felt very hot to
touch over the last 24 hours.
She rang the surgery and
spoke to Dr X, a GP registrar.
Dr X took a history over the
telephone and diagnosed
a “viral illness”. The mother
assumed Dr X would have seen
Z’s records and be aware of her
underlying condition so did not
mention the hydrocephalus or
the shunt during the telephone
consultation. Dr X did not ask
Learning points
n Exercising clinical judgment
based on a telephone
consultation can be
challenging, but even more
so with children. Taking a
good past medical history
is a crucial part of any
telephone consultation,
especially if the patient’s
records are not available.
n Parental concerns are a
good indicator of something
being wrong and should be
taken seriously.
n Non-clinical staff should not
become a barrier between
patients and doctors.
Clear protocols should be
applied, setting out what
is expected of non-clinical
staff in such situations.
n Ensure that you are
employing safety-netting
procedures. In this case
there was an omission
to tell the mother under
what circumstances she
should have contacted the
practice.
www.medicalprotection.org ireland casebook vol. 17 no. 3, SEPTEMBER 2009
23

Case report
Diagnosis; Notekeeping
General Practice
Not just another headache
Mr Q, a 40-year-old man,
booked an emergency
appointment to see Dr A.
He presented with a severe
headache. He told Dr A that
it had come on suddenly
and was very worried as to
the cause, as he had not
experienced a headache like
it before. He had a history of
tension headaches and had
been seen and investigated by
a neurologist during the past
year to rule out other causes
of his recurrent headaches. Mr
Q also had a long history of
anxiety and panic attacks.
© jupiterimages
Dr A documented the
description of the headache
and performed a neurological
examination which was
documented as normal. No
papilloedema was noted.
Mr Q was found to be
systemically well and apyrexial
with no history of fevers,
rash nor photophobia. Dr A
recorded that Mr Q appeared
tremulous and anxious, and
noted his blood pressure
was raised. Dr A diagnosed
an anxiety attack and
provided reassurance and a
prescription for diazepam, to
help settle the acute anxiety.
Two days later, Mr Q requested
a home visit from Dr A, who
attended within the next hour.
Mr Q reported a worsening
headache. He had also started
vomiting overnight and was
now experiencing blurred
vision. Dr A again performed a
neurological examination, and
found no focal signs. Mr Q’s
blood pressure was raised at
a similar level to the previous
assessment.
Dr A still felt that the diagnosis
was likely to be anxiety.
However, the new symptoms of
vomiting and visual disturbance
were suggestive of possible
raised intracranial pressure.
These red flag symptoms, and
Learning points
n Headache is a common
symptom. It is important
to remember the red flag
symptoms that point
to a serious cause. It is
good practice to routinely
document the presence or
absence of these symptoms
in patients presenting with
headache.
n It is vital for any doctor
to keep an open mind to
differential diagnoses and
to be prepared to challenge
their own previous diagnosis
(or that of another doctor) if
the patient’s complaint does
not follow the expected
course.
n Patients with anxiety can
often present with physical
symptoms. Sometimes
these will be a physical
the fact that the headache
had persisted, despite
reassurance and a small dose
of benzodiazepine, led Dr A to
organise urgent admission and
assessment by the medical
team.
expression of emotional
stress – somatization.
However, the converse
can be true in that physical
pain and illness can cause
anxiety. It is important to
bear this in mind when
patients present with
anxiety as well as physical
symptoms.
n When assessing a patient
with a history of anxiety
disorder be careful to
take a fresh and objective
approach.
n Good documentation
should reflect the thought
processes involved in
arriving at a diagnosis or
differential diagnoses. It
should include important
negatives as well as positive
findings in the history and
examination.
Soon after admission,
Mr Q lost consciousness
and collapsed. An urgent
CT scan showed a
subarachnoid haemorrhage.
Mr Q underwent emergency
surgery to relieve the
raised intracranial pressure.
Following the surgery Mr Q
was left with cognitive deficit
and word-finding difficulties.
After his discharge Mr Q began
a claim against Dr A for failing
to diagnose the haemorrhage.
Expert Opinion
The GP experts agreed that Dr
A took an appropriate history
and this was well documented.
It was felt he responded
adequately by questioning
his diagnosis at the second
presentation, and admitting Mr
Q in response to the new red
flag symptoms.
The GP experts supported
the standard of care provided
by Dr A and the claim was
successfully defended.
ZS
24
ireland casebook vol. 17 no. 3, SEPTEMBER 2009
www.medicalprotection.org

Case report
communication; Notekeeping
neurosurgery
A failure of communication
Mr F was a 45-year-old taxi
driver with a three-month
history of neck pain and
tingling in his left upper limb.
After attending his general
practitioner, the patient was
referred to Dr W, a consultant
neurologist.
On initial assessment, Dr W
elicited the additional history
of gradual onset motor
weakness, which was now
causing difficulties when
changing gear. Examination
confirmed unilateral sensory
and motor deficit, with positive
Hoffmann sign. Dr W arranged
baseline blood tests and
imaging. A biochemical and
haematological screen was
normal; MRI was reported as
showing focal enlargement of
the cervical cord consistent with
an ependymoma. Mr F was
referred to Mr A, a consultant
neurosurgeon, for operative
management.
Mr F consulted Mr A the
following week. Mr A took
time to explain the findings
of the MRI, and proposed to
perform a cervical laminectomy
and removal of the tumour.
He explained that, although
the tumour appeared to be
benign, he would need to
confirm this intra-operatively
with analysis of a frozen
section. Mr F was then asked
to sign a consent form, which
listed complications including
bleeding, infection, and
damage to the spinal cord.
Mr F was admitted for surgery
the following morning.
The operation proceeded
smoothly, the tumour was
resectable and the histology
of the frozen section was
reported as benign. However,
despite good haemostasis in
theatre, on the patient’s return
to the ward the dressing
had soaked through with
serosanguinous fluid and
required changing. The ward
staff were exceptionally busy
with another patient and Mr A
reviewed his patients alone on
a postoperative round. Mr A
recorded his review of Mr F in
the medical notes as “19:30 -
Awake. Obs stable. Dressing
dry. Power 5/5 sensation
normal bilaterally”.
The nursing notes for this period
describe that the dressing was
“soaking wet”, and had been
changed twice in a little over
two hours. Unfortunately, this
information was never passed
to Mr A, nor the junior doctor, Dr
P, who was asked to review the
patient overnight. It is recorded
in the nursing notes that Dr P
had reassured the patient, and
asked for a clean gauze to be
applied. There was no specific
entry made in the medical
records.
Mr A reviewed his patients
the following morning before
breakfast. Again, a dry dressing
is noted, but this was not
removed. Over the following
five days, Mr A recorded that
he checked the surgical wound
Learning points
n Communication within a
clinical team is essential to
maintain proper standards
of patient care. This case
highlights the difficulties
which can arise when
information is not passed
between the nursing and
medical teams. The lack
of documentation of any
neurological examination
postoperatively was a
further difficulty in defending
this claim.
n The operation notes
should always include
postoperative instructions
for early identification of any
potential complications.
© Gary Martin/istockphoto.com
three times. The nursing notes
simply state “no bruising, no
swelling”. No neurological
examination was documented
following the immediate
postoperative period.
Mr F was discharged on the
fifth postoperative day, but
presented almost immediately to
A&E with weakness and sensory
loss distal to the surgical
wound. MRI demonstrated a
large haematoma in the soft
tissue and a coexistent epidural
haematoma, with consequent
compression of the cord at C3-
5. Despite surgical evacuation,
Mr F unfortunately remained
quadriplegic.
Solicitors acting for Mr F issued
a claim against the hospital and
Mr A. MPS settled the claim for
a high sum, with a contribution
from the hospital on behalf of
the nursing staff.
CG
Nursing staff cannot be
expected to be familiar with
every surgical procedure or
the postoperative risks.
n The preoperative consent
process must be well
documented. The written
information on a consent form
should be supplemented
with a detailed discussion,
and this conversation clearly
documented in the clinical
record.
n It is good practice to
ensure that patients receive
a written account of the
consultation and receive
copies of correspondence
between hospitals and
primary care services.
www.medicalprotection.org ireland casebook vol. 17 no. 3, SEPTEMBER 2009
25

REVIEWS
Reviews
BOOK REVIEWS
How Doctors Think
Jerome Groopman
Published by Mariner Books
ISBN: 978-0547053646
Reviewed by Dr Alison Metcalfe, MPS
Head of Medical Services (London)
How often do we as doctors
stop to consider how we think
about our patients – their
symptoms, their situation and
their diagnoses? The answer is
probably seldom, if ever. Time
pressures are such that the
opportunity for such reflection
is, increasingly, limited. Jerome
Groopman’s How Doctors Think
makes a compelling case for
finding that time which may help
the practitioner avoid the hazard
of falling into the cognitive
pitfalls that lie in wait for the
unwary.
The author tries to tease out the
way doctors think about their
patients and where cognitive
pitfalls lie. By becoming
conscious of the potential
origins of clinical misjudgment
he considers that this will, in
itself, help to prevent falling into
such traps.
Groopman explores various
cognitive pitfalls, through case
scenarios and interviews with
experienced clinicians, who
reflect on how their way of
thinking may have influenced
the outcome for the patient.
The wide-ranging contributions
to this book attest to the
vulnerability of even the most
experienced clinician.
Groopman was first moved to
ask the question about how
a doctor thinks when he saw
his junior doctors scrutinising
algorithms to make a diagnosis
and invoking statistics to decide
on treatment. He realised that
they were operating in a narrow
and programmed way, making
little allowance for the patient
as an individual. He felt that
there was something profoundly
wrong in approaching clinical
diagnosis in this way, with a
passive choice of care using
linear and vertical thinking which
would be confused by vague or
non-specific symptoms.
The author tries to
tease out the way
doctors think about
their patients and
where cognitive
pitfalls lie
Reading this book you quickly
realise how easy it is to fall into
those cognitive pitfalls. Take the
concept of “search satisfaction”
– stopping the search after the
first positive finding secures a
diagnosis. If you stop searching,
you stop thinking; entirely
understandable, but important
to be aware of to avoid missing
something else. Then there
is categorising patients too
early, making us blind to their
problems. A more obscure pitfall
is our natural preference to
focus on positive – that which
fits comfortably with a diagnosis
– rather than negative data.
The list continues – increasingly
uncomfortable, but compelling,
reading.
The point that really comes
across is the importance of
time to think and reflect, so
this is also a book for health
economists, planners and
managers. It highlights the
risk that decreasing a doctor’s
available time to think can only
lead to an increase in error.
It is also a book for educators,
to ensure that not only are all
medical students and doctors
aware of these cognitive
pitfalls, but also how algorithms
and statistics as a method of
speeding up diagnosis and
choosing treatments could
channel our thinking, risking us
reaching the wrong conclusion
or perhaps no conclusion at all.
Finally, the author proposes
that, as doctors, we harness
the help of the patient by
encouraging them to ask those
questions that will make us
think again. “What else could
it be?”, “What doesn’t fit with
the diagnosis?”, “Could there
be more than one thing causing
the problem?” Now there’s a
challenge.
26
ireland casebook vol. 17 no. 3, SEPTEMBER 2009
www.medicalprotection.org

OVER TO YOU
Over to you
We welcome all contributions to Over to you. We reserve the right to edit submissions.
Please address correspondence to: Casebook, MPS, Granary Wharf House, Leeds LS11 5PY, UK
Email: casebook@mps.org.uk
The challenging
patient
I was interested in the article
on “The challenging patient”
which appeared in the last
issue of Casebook.
My consultant in Ashford in
Middlesex was Alan Barham
Carter, who once showed
me an article he had written
which he had called the
“White-knuckle syndrome”.
This consisted of white
knuckles and four crescentic
marks on the palm; however,
these were exhibited not
on the patient, but on the
physician. He then went on
to say that when you saw
this syndrome in yourself you
should redouble your efforts
to find an organic cause
for the patient’s symptoms,
because patients that irritate
or upset you might still have
something significantly wrong
with them. However, your own
emotions might get in the way
of taking them seriously. This
is essentially what you were
saying in the article.
I have tried to find a copy of
Dr Carter’s article but in vain.
It must have been published
before 1969/70, when I was
his house physician.
Karl Fortes Mayer
Consultant Surgeon (UK)
PS I have been instructing my
juniors about this syndrome for
the last 30-plus years
(Ed’s note: if anyone has
information on, or a copy of, the
above article by AB Carter then I
would be very glad to pass it on.)
Tangled web
It would be childish to deny the
web and internet as they are here
to stay. The internet provides an
incredible source of information to
patient and doctor alike. However,
any innovative system must have
pros and cons and in its infancy
experience teething troubles.
Undoubtedly the millions of
websites available will have very
good and very bad sites for many
reasons – some for monetary
gain, some due to ignorance,
some to create mischief, etc.
But, that said, some doctors
need to be given a wake-up call
that the internet is here to stay
and the sooner they become
conversant with it the better.
Patient education is very much
part of modern medicine. But
if the public are left to wander
through the quagmire of the
internet unassisted, it can only
lead to chaos and consternation.
Thus it is incumbent for any
self-respecting doctor to be up
to date with their knowledge of
medicine as a whole so as not
to be caught out. They must
also be able to advise patients
which websites are worthwhile
and informative and which are
dangerous.
I advise on “adders.org” in the
UK and on “allexperts.com” in
Casebook is also available to download in digital format from the
website at www.medicalprotection.org
the USA on ADHD. Judging
by the type of questions put
to me on these internet sites,
there is an urgent need to
educate doctors about this
condition, in my opinion. If this
is correct, one may assume
the same need might exist with
many other medical conditions.
However, my advice on the
internet is always intended as a
comment to be discussed with
a patient’s own doctor.
Just an interesting fact about
surfing the internet. It appears
to be beneficial to the elderly in
retaining their cognitive ability
and delaying senility. Might that
not benefit all doctors?
Dr WJ (Billy) Levin (SA)
www.medicalprotection.org ireland casebook vol. 17 no. 3, SEPTEMBER 2009
27

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