Dr Marika Davies, medicolegal consultant, looks at a recent case in the United Kingdom, where the death of a 77-year-old patient raised questions over where the liability for the negligence lay: with the junior doctor or the consultant?

The case

GA v Greater Glasgow Health Board [2019] CSOH 31

A 77-year-old woman, Ms J, was seen by an out-of-hours GP with a 24-hour history of abdominal pain and multiple episodes of vomiting and diarrhoea. He referred her to the acute admissions unit (AAU) where she was seen by Dr I, a junior doctor. Ms J had attended with similar symptoms the previous day and had been discharged with a diagnosis of gastroenteritis and oral medication, but she had worsened and now described her vomit and stools as black. Her partner reported they were not coping at home.

Ms J’s past medical history included a cardiac arrest 18 years ago, hypertension and chronic obstructive pulmonary disease, and she was an ex-smoker and usually independent. On examination, her abdomen was soft and non-tender, with bowel sounds present. There was no evidence a PR had been carried out and her observations were within normal limits. An ECG was normal, and CXR and AXR were normal with WCC 12, urea 8.4, CRP 25, Hb 14.2 (which had been 14.8 the day before). Ms J was not currently symptomatic, except she was noted to ‘spike’ a temperature of 38 while in the AAU. There was then an improvement in her early warning score and she started to tolerate oral fluids.

Dr I recorded that his clinical impression was one of likely gastroenteritis. In terms of a plan, he documented that the “patient would like to go home” (a fact that was later disputed in evidence by Ms J’s partner). Dr I discussed the case with a consultant over the telephone, in line with departmental policy. He wrote in the notes that as Ms J was able to look after herself and able to drink, she should go home. She was advised that if she got worse, she should come back in. Ms J was again prescribed antiemetics for nausea and vomiting.

The consultant, Dr C, would later refer to this in his evidence, stating that he would have made sure that Dr I went over all the findings and results with him in their telephone call. The discussion would have been a detailed one. Dr C explained that he must have been reassured by the information presented to him that it was appropriate to discharge the deceased.

After discharge home, Ms J’s condition deteriorated with further vomiting and diarrhoea. The following day, her partner called for an ambulance as she was unable to get up from the bathroom floor; she was taken to the ED and was confused, clammy and sweaty, and an ECG showed she was in fast atrial fibrillation. That night a further AXR showed dilated loops of the small bowel centrally, and CRP of 287. Ms J was reviewed on several occasions during the night and a CT angiogram was done early the following morning – at 08.30 an entry was made in the medical records that this had shown a superior mesenteric artery thrombus just distal to the origin of the right hepatic artery. The appearance was consistent with an ischaemic bowel.

An emergency laparotomy followed – there was significant necrosis through almost all the small bowel, and a large portion of the right colon was also ischaemic. Resection was not possible because there was no viable small bowel. Ms J’s condition had deteriorated to the point that she could not survive, and she died shortly afterwards.

Ms J’s partner brought a claim against the NHS Trust responsible for the hospital, alleging a failure to do a rectal examination and failure to admit; if these had happened, Ms J would not have died. The case went to trial and Ms J’s partner was successful, with substantial damages awarded.

Learning points

• Dr I had no recollection of seeing or examining Ms J and so relied entirely on his medical records when giving evidence at the trial. Likewise, Dr C had no recollection of Ms J, of his discussion about her with Dr I, or of Dr I himself. This case highlights yet again the importance of keeping clear and accurate medical records, which should include details of all relevant discussions and negative findings.
  
  
• The judge was clear in his summing up that Dr I was not expected to have made the diagnosis of bowel ischaemia, but that he should have suspected a serious intra-abdominal abnormality. As such, he was negligent in failing to advise Ms J that she should be admitted to hospital.
  
  
• Although Dr I had documented that the patient wanted to be discharged and could cope at home, the judge did not find this to be an accurate reflection of the situation. Considering all the evidence, including the accounts of the on-call GP and the partner (who reported begging the doctor to admit the patient), he found there was a substantial body of evidence to suggest that the patient and her partner were not coping at home, and concluded that she would have agreed to admission if this had been offered.
  
  
• The fact that Dr I discussed the case with Dr C did not, in the judge’s opinion, absolve Dr I of liability for having failed to advise Ms J that she should be admitted. The judge further commented that Dr C’s advice was based on inaccurate information that Ms J could cope at home, and for this inaccuracy Dr I was liable.