Chapter 1 - Investigations
Jump to
Case No. W.138/97-98
The care provided to Ms J by Dr B, a general practitioner
Complaint against
Dr B, a general practitioner in the North Wales HA area
Complaint as put by Mr J
1. The account of the complaint provided by Mr J was that on 18 July 1997, his sister, Miss J, travelled to a holiday centre for a short holiday. During the preceding few days she had complained of muscle pain and lethargy. She again felt unwell on the journey; and on the following day, 19 July, she attended Dr B's surgery at the centre. Dr B examined Miss J, who complained of stomach pain and nausea and that she had been vomiting for two days and was slightly constipated. She also said that she had been diagnosed as having Mature Onset Diabetes of the Young (MODY) (a form of non-insulin dependent diabetes) and had not tested her blood glucose levels. Dr B diagnosed gastritis and prescribed Maxolon, an anti-nausea medication. Miss J continued to feel unwell and, on 20 July, returned to her home in Widnes, where she was seen by a locum GP (the second GP) on 20 July and her own GP (the third GP) on 21 July. She was admitted to hospital on 22 July suffering from diabetic ketoacidosis (an excess of acid and ketones - an organic compound - which may be present in the body tissues and fluids, which develops in diabetics when their condition is getting out of control, and may indicate approaching coma). She died on 31 July.
2. Mr J complained to the practice about the treatment Dr B gave his sister and subsequently requested an independent review of his complaint. The independent review was held on 6 January 1998; but Mr J remained dissatisfied. The conduct of the independent review is the subject of a separate investigation by the Commissioner.
3. The matter subject to investigation was that Dr B's clinical management of Miss J's condition was unsatisfactory in that:
(a) he took insufficient steps to diagnose and treat her condition, in particular, he failed to test glucose and ketone levels; and
(b) he failed to ensure that she had sufficient knowledge to manage her diabetes in the light of her symptoms.
Investigation
4. The context of this investigation is that Dr B was the first of three GPs who saw Miss J between 19 and 22 July 1997, when she was admitted to hospital. The actions of the two GPs who saw her after her consultation with Dr B were subject to complaint by Mr J: in both cases the Health Authority commissioned independent reviews to consider the adequacy of the care they gave. Dr B's actions were also subject to independent review, following which Mr J remained dissatisfied and approached the Commissioner. Dr B came to the same diagnosis as the two GPs who saw Miss J later. The actions of the two GPs were criticised by the independent review panels. The panel which considered the actions of the second GP who saw Miss J on 20 July, concluded that he should have tested her blood and in failing to do so fell below the standard of a reasonable GP. The panel that considered the actions of the third GP, who saw her on 21 July, concluded that he should have established her current blood sugar level, preferably by checking it himself, and that because he failed to do this his standard of care was not of an acceptable level.
5. The statement of complaint for the Commissioner's investigation of the complaint against Dr B was issued on 1 April 1998. I obtained Dr B's comments on the statement; and relevant documents were examined. One of the Commissioner's investigating officers took evidence from Mr J, Miss J's fiancé and Dr B. Two external professional assessors (the Commissioner's clinical assessors) were appointed to give independent advice on the clinical issues central to this case, which are about whether, when he saw Miss J on 19 July, Dr B acted in a way consistent with reasonable clinical practice (see paragraph 7). The assessors have expressed an opinion on the reasonableness of Dr B's actions given the information he had or might have elicited when he saw Miss J. They have not, rightly, taken account of subsequent events, including Miss J's later care in hospital. The assessors were unable to say whether Miss J would have survived had Dr B acted differently. The assessors' report is at Appendix A. A note on technical terms used recurringly in this report is at Appendix B. I have not put into this report every detail investigated; but I am satisfied that no matter of significance has been overlooked.
Relevant legislation and national guidance
6. The National Health Service (General Medical Services) Regulations 1992, include at section 26(1) that "A person requiring treatment who .... is not on the list of a doctor providing general medical services in the area of the locality where he [she] is temporarily residing .... may apply to any doctor providing services in the locality in which he [she] is temporarily resident to be accepted by him as a temporary resident". The regulations interpret 'treatment' to mean 'medical attendance and treatment .... ' but to exclude health surveillance, contraceptive, maternity, medical and minor surgery services.
7. Schedule 2 of those regulations contains the terms of service for doctors, which include:
'Where a decision whether any, and if so what, action is to be taken under these terms of service requires the exercise of professional judgment, a doctor shall not, in reaching that decision, be expected to exercise a higher degree of skill, knowledge and care than -
' .... that which general practitioners as a class may reasonably be expected to exercise.'
Professional guidance
8. Guidance from the General Medical Council entitled 'Good Medical Practice', in the edition published in 1995 (before the events subject to complaint), describes good clinical care as including:
'- an adequate assessment of the patient's condition, based on the history and clinical signs including, where necessary, an appropriate examination;
- providing or arranging investigations or treatment where necessary .... .
- [keeping] .... clear, accurate, and contemporaneous patient records which report the relevant clinical findings, the decisions made, information given to patients and any drugs or other treatment prescribed.'
Evidence of Mr J and Miss J's fiancé
9. On 23 October 1997, Mr J wrote to Dr B's practice manager making a formal complaint against Dr B. He said that Miss J had presented at Dr B's surgery with signs of hyperglycaemia (an excess of sugar in the blood) - vomiting, nausea, stomach pains and thirst. She told him she was diabetic, but Dr B failed to carry out a blood or urine test.
10. On 23 January 1998, Mr J complained to the Commissioner that his sister had attended Dr B's surgery as a temporary resident, and clearly identified herself as a diabetic who had been vomiting for two days. Mr J wrote:
'Knowing that [Miss J] was a diabetic Dr B failed to enquire about or test diabetic control. The only safe way for Dr B to have proceeded was to have actually tested blood glucose levels and urine ketone levels .... knowing [Miss J] was a diabetic he failed to ensure that [Miss J] understood the implications of this vomiting and understood how to manage her diabetes during illness. These measures are widely accepted as good clinical practice ....
'It is our position that to fail to test diabetic control in an identified diabetic patient if the patient is vomiting .... is acting without regard for the danger of the loss of diabetic control which can be fatal. We feel that .... had Dr B checked diabetic control .... he would have found definitive signs of hyperglycaemia and diabetic ketoacidosis. Had this been the case and [had] appropriate treatment been commenced then .... [Miss J] would be alive today.'
11. When interviewed Mr J said that his mother telephoned him on 20 July (the day his sister returned home from the holiday camp), and said that Miss J was unwell and had been seen by a doctor (the second GP). His mother had put her concerns about a link between diabetes and her daughter's illness to the doctor, but the second GP said that her daughter had a viral infection. On 21 July, Mr J's mother told him that a doctor (the third GP) was coming to see his sister. On 22 July his mother told him that his sister was being taken to hospital. Mr J visited his sister in the intensive care unit (ITU). She told him that she had seen a doctor whilst on holiday and had told him that she was diabetic, was vomiting, and had tummy pain. The doctor (Dr B) had not told her what he thought was wrong, but had given her some medicine. The next day Mr J spoke to Miss J's fiancé, who told him that he had accompanied her to see a doctor whilst on holiday. Mr J told the investigator that Dr B knew that Miss J was a diabetic and was vomiting. He said that Dr B asked her whether she was testing her blood and she said she was not. [Note: a test record maintained by Miss J and seen by the investigating officer records that Miss J did test her blood sugar levels. Her last recorded reading was taken on 14 July 1997 and was 11 millimoles]. Mr J thought that 'giving safety net advice' ['come and see me if you are not better'] was not enough for a diabetic at risk of losing diabetic control. Mr J considered that Dr B should have tested Miss J's blood and urine and ensured that she knew how to manage her diabetes during illness.
12. On 23 November 1997, Miss J's fiancé (the fiancé) made a signed statement which includes:
'On the way to the holiday park [Miss J] .... began to feel ill with tummy pains and feeling sick. Shortly after arrival at the park [Miss J] was actually sick a number of times and was unable to keep any food or drink down. The minute she ate or drank it just came back.
'As she had not got any better I asked her to go to the doctor's at the camp ....
' .... we went into the room .... the doctor asked [Miss J] what the problem was. [Miss J] told him that she was a diabetic, she told him she was MODY and was diet controlled .... that she had been feeling unwell for 2 days, she had been feeling sick, she had vomited, she had a tummy ache and was feeling thirsty. I added that she had been unable to keep any food or drink down .... the minute she ate or drank she would throw it straight back.
' .... At no time did the doctor enquire about [Miss J's] diabetes nor did he carry out a blood test or anything really .... The doctor certainly did not tell [Miss J] to come back and see him nor did he tell her that she could call him out in the night if her illness continued ....
'At about 4 o'clock in the morning on the 20th July 1997 [Miss J] woke up constantly vomiting and crying .... I took her home.'
13. When interviewed, the fiancé said that he and Miss J went to the holiday centre with his cousin, his cousin's partner, and their baby to celebrate his cousin's 21st birthday. Miss J had begun to complain during the car journey that she was feeling 'a bit ill'. They arrived at the centre at 10.30 am, got their keys, unpacked, and then walked around to see the shops and arcade. They went to the centre's club in the evening. Miss J was feeling a little unwell, but did not want to spoil the evening and so 'put up with it'. They left the club early because of the baby and went to bed. During the early hours of the morning Miss J was 'being sick constantly'. The fiancé did not see Miss J being sick, but heard her retching. He persuaded her to visit the camp doctor, and they walked to the surgery at about 4.00pm. Miss J filled out a form. In the surgery she told the doctor that she had been vomiting, was 'constantly thirsty', and could not keep anything down. The fiancé told the doctor that Miss J's diabetes was diet-controlled. Dr B asked no questions about Miss J's diabetes and did not ask her whether she tested her blood or urine. Dr B examined Miss J's abdomen and she told him that some areas were tender to the touch. She said she was slightly constipated. Dr B gave Miss J a prescription, instructed her to take the syrup, and said that she 'would be right as rain in the morning'. Dr B did not give Miss J his diagnosis, but the fiancé told the investigating officer that he thought he mentioned 'gastritis' and that that was why he was checking her stomach. Dr B did not tell Miss J what to do if she continued to feel unwell.
14. Miss J took the medicine, but it did not help. She continued retching, and was either sick or retched whenever she tried to eat or drink. At about 4 o'clock the following morning Miss J awoke and was continuously vomiting and crying. Her fiancé heard her retching; and she asked him to take her home. The fiancé said that he did not know how to contact Dr B: there was no notice in their caravan, and he thought the surgery would not open again until 4.00pm. He took Miss J home.
Documentary evidence
15. Dr B completed a temporary resident record for Miss J, as follows (see explanations in paragraph 24):
'Vomiting 2/7 ab[domen] (tick)
'BO [bowels open] (tick) M.O.D.Y.
'Rx [treatment] Maxolon Syr[up]'
'21/8/97 - message from brother
'Mr J ....
'S/B [seen by] locum Widnes 20/7
' own GP 21/7
'admitted 22/7
'Died in hosp[ital] 31/7 .... '
16. On 20 July 1997, Miss J was seen at home by a locum GP (the second GP). He recorded:
'History
'Abdo[minal]-pain : vomiting since last Fri[day]
'Bowels (tick)
'Diabetic on diet control
'Clinical examination
'Anaemia (nil) Jaundice (nil)
'Well hydrated
'Abdo[minal] tenderness [a diagram sited pain in the lower left quadrant] no guarding, no lumps LKKP [no lumps felt in liver, spleen or kidneys]
'Temperature 35.7C Pulse 80bpm [beats per minute] BP [blood pressure](no entry).
'Diagnosis - Gastritis'
17. On 21 July 1997, Miss J was attended by the third GP who recorded the following in her clinical notes:
21.7.97 Vomiting 3/7. Given stemetil liquid by locum. Makes her sick. O/E [on examination] Not dehydrated. [Abdomen] soft non tender. RS [respiratory system] NAD [no abnormality detected] No genito-urinary or gastrointestinal symptoms. RBS [glucose level] around 7. PU [passing urine] normally. Diagnosis Gastritis.'
18. The transcript of evidence to the independent review panel which considered Mr J's complaint about the third GP includes a statement by him that he did not associate Miss J's symptoms with diabetes because she did not look ill, did not appear to be vomiting, her breath did not smell of ketones, she was not clinically dehydrated, she denied passing large amounts of urine, and was normal mentally. Miss J's mother told him that her daughter's blood sugar was around 7 millimoles per litre.
19. The post-mortem report, dated 1 August 1997, lists Miss J's cause of death as acute cerebral oedema [an excess of fluid in the brain] and diabetic ketoacidosis.
20. The conclusions of the report of the independent review of Mr J's complaint against Dr B include:
' .... whilst MODY was recognised in [Miss J], no specific steps were taken by Dr B to establish the precise nature of [Miss J's] diabetic condition ....
'If [Dr B's notes] do not record relevant negative findings which were drawn [by him] then we conclude that they would fall below the requirements of good practice.'
Dr B's evidence
21. In his formal response to the Commissioner, conveyed in a letter from Solicitors, Dr B said that he had a 'normal, intelligent' conversation with Miss J about her illness. She told him that she had been vomiting on and off since the previous day, that she was a diet controlled diabetic, and that MODY had been diagnosed by a hospital consultant. Dr B explained to her that an upset stomach could be a sign that her diabetes was not under proper control. He wanted to establish, therefore, whether she had any symptoms of ketoacidosis or hyperglycaemia. He asked her whether her diabetes was 'playing up'. Miss J told Dr B that she was not testing her blood sugar levels. Dr B added:
'Miss J did not tell [me] she had "tummy pain" and "thirst" as set out in Mr J's letter .... If she had complained of these symptoms [I] would immediately have suspected a diabetic cause .... and arranged further investigation. These are classic symptoms of diabetes which simply were not present at the time .... [I] did specifically ask her whether she was drinking more than normal and whether she was passing water more often than normal. Her answer .... was no .... '
22. The statement said that Dr B examined Miss J's abdomen which was unremarkable. She said that she did not have any pain; that her bowels had been open; and that she had had no diarrhoea. She was able to climb on and off the examination couch without difficulty. Dr B smelt Miss J's breath and excluded any smell of ketones and fetor (an unpleasant smell). She was not dehydrated and did not appear lethargic. Dr B's clinical assessment was that her diabetes was not relevant to the presenting complaint of vomiting. She denied any symptoms associated with hyperglycaemia or ketoacidosis. Dr B was also reassured by the diagnosis of MODY because type 2 diabetics (non-insulin dependent) were very unlikely to develop a ketoacidotic state in the absence of severe illness or infection. He said:
'It is admitted that [I] did not test glucose and urine ketone levels but it is denied that the patient's clinical condition or history given at the time of the consultation required such steps'.
23. Dr B also denied that he failed to ensure that Miss J had sufficient knowledge to manage her diabetes in the light of her symptoms.
24. Dr B told the Commissioner's investigating officer that his practice had an agreement with the holiday centre to provide medical cover seven days a week. When Miss J walked into his surgery she did not appear at all ill. Dr B had not been called out to visit Miss J, as he would have expected had she felt very ill. Dr B said that Miss J was not sick whilst in his surgery and was well enough to fill out a form on arrival. She was not clutching a bowl or receptacle to be sick in, as Dr B would have expected if she was nauseous. Miss J said that she had been vomiting and was MODY. Dr B questioned her about her diabetic control. She was unable to tell him what her sugar level was. Dr B asked about polydipsia (excessive thirst) and polyuria (excess urine production) and used this as a crude screening process to exclude hyperglycaemia in a type 2 diabetic. He asked Miss J if she was thirsty and she said no. If she had been a true type 2 diabetic Dr B believed that she would have been very unlikely to develop diabetic ketoacidosis in the absence of acute infection or serious illness - which she did not have. Had Miss J appeared ill, Dr B said that he would have tested her blood sugar; but he saw no indication that such a test was needed. Dr B said he was surprised when Miss J told him that she did not test her own blood or urine; and he suggested to her that she should contact her GP about this as, if she was a true type 2 diabetic and did not monitor her sugar levels, she might develop problems in the long term. Dr B said that, with hindsight, he would have tested her; but at the time she looked well, the vomiting appeared to have stopped, and she appeared quite comfortable. She was a type 2 diabetic MODY, and Dr B did not consider her to be at particularly high risk of developing diabetic ketoacidosis.
25. Dr B said that he wrote short notes of the consultation as an 'aide memoire'. He was on call that weekend, and so could have seen Miss J again if she had needed a doctor. Dr B usually recorded important facts in his notes. The degree of detail varied from patient to patient according to need. He explained that, in Miss J's case, 'abdomen - tick' (see paragraph 15) meant that nothing abnormal had been found; if her abdomen had been tender he would have drawn a diagram to indicate where. 'BO (bowels open) - tick' meant that there was no diarrhoea or constipation. 'Vomiting 2/7' meant that she had been vomiting for two days - the day of the consultation and the day before. Dr B said that he had diagnosed gastritis based on a history of vomiting with no obvious cause, where the vomiting had ceased and the patient recovered - which Dr B believed was what appeared to have happened in Miss J's case. He had established during their conversation that she was keeping some fluid down and did not appear dehydrated. Dr B said that he smelt Miss J's breath during the examination to exclude the presence of ketones or fetor. At the time of the consultation it seemed reasonable not to test Miss J's blood sugar. Dr B said that he was now 'extra cautious' and tested all diabetics he saw. However, his judgment at the time was that there was no need for him to test Miss J.
Clinical Assessors' advice
26. The Commissioner's assessors' report (at Appendix A) concludes:
' - Dr B took a reasonable history for someone who at the time of being seen did not present as particularly ill;
- Dr B should have recorded both positive and negative findings in view of Miss J's past medical history and diagnosis;
- There is a range of views as to whether urine or blood should be tested for glucose in a diabetic with a history of vomiting. If it is accepted that Miss J was not particularly ill at the time she was seen it may not have been necessary in her case. However, it would probably be considered good practice to test urine in a diabetic patient, presenting with vomiting, when this was not being undertaken by the patient;
- Dr B's note-keeping was not comprehensive enough;
- It was not Dr B's responsibility to educate Miss J about diabetic management.'
Findings (a)
27. Mr J has complained that Dr B should have tested Miss J's urine and blood when he saw her as a temporary resident patient at the holiday centre on 19 July 1997 and that, had he done so, she might be alive today. I recognise the distress and anger the family have experienced as a result of that belief. My findings in this case focus on whether Dr B did all that could reasonably be expected of a competent general practitioner in the circumstances.
28. Having accepted Miss J as a temporary patient at the holiday centre, under the provisions of section 26(1) of the General Medical Services Regulations (paragraph 6), Dr B had a responsibility to provide no less a standard of care and treatment to her than to a patient seen in his own practice. Miss J presented on 19 July as a patient Dr B did not know and who told him that she had been vomiting and was diabetic in the form of the relatively unusual condition MODY.
29. There is no dispute that Dr B did not test Miss J's blood sugar or urine. His reason for not doing so was that MODY carried a low risk of ketoacidosis in the absence of severe illness or infection, and he did not consider that Miss J presented as particularly ill when he saw her. It is certainly true that Miss J was able to go out with friends the night before; was able to walk to the surgery; and was not sick while there. Had Miss J not been diabetic it is unlikely that there would have been reason to question Dr B's diagnosis and treatment of what he deduced was gastritis - a diagnosis also made later by the second and third GPs (paragraph 4). However, Dr B knew that Miss J was diabetic and was unwell, and he believed that she was not testing her own blood sugar. My findings must turn on whether he paid sufficient attention to these factors when he saw her.
30. There is a conflict of evidence between Dr B's and the fiancé's accounts of what happened in the course of the consultation on 19 July. Dr B maintained that he considered the possibilities of hyperglycaemia and ketoacidosis, but excluded them on the basis of questions he put to Miss J and the answers she gave; the fact that she was not dehydrated, had no smell of ketones on her breath and no report of thirst or excessive urine production; and the diagnosis of MODY. Dr B said that Miss J told him that she was not testing her blood sugar levels. On the basis of the history he took, Dr B diagnosed gastritis, for which he prescribed Maxolon and advised Miss J to return or call him out if she continued to feel unwell. The fiancé said that Dr B asked no questions about Miss J's diabetes and that she gave a different account of her symptoms.
31. Unfortunately, Dr B did not make a full record of the questions he asked Miss J and the answers she gave. Dr B said that his practice was to vary the content of his notes according to the needs of each patient but to record important detail. In Miss J's case the sole reference to diabetes in Dr B's notes is 'MODY'. His notes are brief in the extreme (paragraph 15) indicating negative findings only by a tick against 'abdomen' and 'bowels open'. There is no tick against 'MODY' to indicate that Dr B excluded symptoms associated with diabetes. These limitations make it impossible for me to decide between the two accounts of what happened at the consultation. The Commissioner's assessors have advised that Dr B's note-keeping was not comprehensive enough and that he should have recorded both positive and negative findings, in view of Miss J's past medical background and diagnosis. I agree; and I recommend that Dr B should ensure that he keeps a full record for all his patients, including temporary residents, which includes both positive and negative findings.
32. Should Dr B have tested Miss J's blood sugar and ketone levels? The Commissioner's assessors advise that there is a range of views within the medical profession on the need to test routinely diabetic patients who present with vomiting. They add that if it is accepted that Miss J did not appear particularly ill at the time she was seen, it follows that it might not have been necessary to test her blood and urine. However, Dr B was not faced with a routine situation. Miss J was seen as a temporary patient, and Dr B had no more information available than he elicited in the course of the consultation. On the question of testing blood sugar, Dr B says (paragraph 22) that Miss J said that she was not testing her own blood or urine, and that he was surprised about that. Although the investigation has revealed a record (paragraph 11) that Miss J did test herself, I have no reason to think that Dr B knew that. At best (according to his own account) he was surprised to be told that she had not tested. At worst (according to the fiancé's account) the subject did not come up at the consultation. Whichever account is true, according to the Commissioner's assessors it would have been good practice for Dr B to have acted with greater caution and at least tested Miss J's urine, in the absence of knowledge that Miss J was testing herself. I accept that advice. I conclude that it would have been good practice for Dr B to have tested Miss J; and I uphold this aspect of the complaint to that extent. I note that Dr B now routinely tests the blood sugar of diabetic patients.
33. In upholding this aspect of Mr J's complaint I should like to make two observations. First, neither I nor the Commissioner's assessors are able to say whether had Dr B, or any of the GPs who saw Miss J, acted differently she would have been alive today. To do so would be speculative for the reasons set out in paragraphs 4 and 5 above. Secondly, the totality of Miss J's care in the period between 19 July and 31 July, when sadly she died, has been the subject of investigation through the complaints procedure or will be the subject of investigation by the Commissioner. He intends to consider when all the investigations are complete whether there are issues related to the general question of diabetic care which he should draw to the attention of the Secretary of State. He, his advisers and the medical profession might wish then to consider whether there is a need for review of the guidance on professional practice in the management of acute diabetes.
Findings (b)
34. Mr J also complained that Dr B had a responsibility to ensure that Miss J understood how to manage her diabetes during an episode of illness. Dr B disagreed, and said that he advised Miss J to speak to her own GP about testing her blood glucose because of the risk of long-term complications for type 2 diabetics. He also said that he told Miss J to come back to see him, or call him out, if she remained unwell. The fiancé denied that Dr B gave advice on either matter. Again, in the absence of contemporaneous records, it is not possible to decide between these accounts. The Commissioner's assessors have advised that, in their view, it was not Dr B's responsibility to attempt to provide diabetic management advice to Miss J. I agree. She was a temporary patient who was feeling unwell and, therefore, might not have been in the best position to be receptive to or retain such information. I do not uphold this aspect of the complaint.
Conclusion
35. This report is of one of a series of investigations into aspects of the care of Mr J's sister and how his complaints were handled. I have set out my findings in paragraphs 27 to 34 on his complaints against Dr B. Dr B has agreed to implement my recommendation in paragraph 31 and has asked me to convey to Mr J - as I do through my report - his apology for the shortcomings I have identified.
March 1999
Appendix A - Report by the Professional Assessors to the Health Service Ombudsman for Wales of the clinical judgments of staff involved in the complaint made by Mr J
Professional Assessors
First Assessor
Dr L - MB BS DTM&H D.ObstRGOG
General Practitioner for 29 years
Senior Partner in a four doctor, seaside town practice
Second Assessor
Dr N BSc MB ChB
General Practitioner for 11 years
Senior Partner in a four doctor, inner city practice
Matters considered
36. The matter subject to investigation is that Dr B's clinical management of Miss J's condition was unsatisfactory in that:
a) he took insufficient steps to diagnose and treat her condition, in particular, he failed to test glucose and urine ketone levels (a ketone is a chemical which is present in the urine when diabetes is not in good control); and
b) he failed to ensure that she had sufficient knowledge to manage her diabetes in view of her symptoms.
Basis of report
37. In formulating our report, we have perused a set of documents and reports which have been made available to us by the Office of the Health Service Commissioner, and which have included:
Report of the independent review panel regarding the late [Miss J], dated January 1998.
Papers considered by the independent review panel on 6 January 1998, including:
1. the original complaint
2. the response from the GP, Dr B
3. a copy of the Temporary Resident Clinical Record
4. correspondence requesting the independent review
5. the statement from [the fiancé]
6. additional information to support the complaint by [Mr J]
7. Letter to the Health Service Commissioner for Wales from [Mr J], dated 23 January 1998.
8. Response to the complaint against Dr B, prepared by Solicitors, dated 5 May 1998.
9. Notes of the interview between the Commissioner's investigator and [Miss J's] fiancé dated 29 July 1998.
10. Notes of the interview between the Commissioner's investigator and [Dr B] in the presence of the first and second assessor dated 19 August 1998.
Assessors' comments on the actions of Dr B
38. We have noted that Miss J was diagnosed MODY in July 1996.
On 18 July 1997, Miss J complained of 'tummyache' and nausea on a journey to [the holiday centre].
In the early hours of 19 July 1997, Miss J started vomiting.
At 4pm on 19 July, she attended a surgery, and saw Dr B at approximately 4.30pm.
According to the clinical record made by Dr B, Miss J gave a history of vomiting for 12 hours (he actually wrote 'vomiting for two days' by which we understand that he meant 'yesterday and today').
Dr B noted that she had Maturity Onset Diabetes of the Young.
Dr B noted that her bowels were normal.
Dr B examined her abdomen and found no abnormality.
We believe that Dr B formulated a diagnosis of gastritis, although this is not recorded in the clinical record.
Dr B prescribed maxolon syrup.
We have noted that Miss J did not vomit whilst with Dr B, and probably did not vomit again until 4am the next morning, when it was decided that Miss J should travel home, rather than call a doctor out at [the holiday centre].
We have noted that there is some discrepancy as to whether Dr B did ask Miss J whether she checked her own blood or urine. Unfortunately, this is not recorded on the clinical record.
We have noted that Dr B neither tested her blood nor urine during the consultation.
Although it is not recorded in the clinical record, there is nothing to suggest that at the time that Miss J was seen, she had ketones.
Conclusion
39. (i) In considering all the evidence, we are of the opinion that Dr B took a reasonable history of someone who, at the time of being seen, was not particularly ill.
(ii) We believe that, in view of her past medical history and diagnosis, Dr B should have recorded both positive and negative findings.
(iii) It would be fair to say that there is a range of views as to whether urine or blood should be tested for glucose in a diabetic with a history of vomiting. If we accept that Miss J was neither particularly ill nor vomiting at the time that she was seen, then it may not have been necessary. However, it would probably be considered as good practice to test the urine in a diabetic patient, presenting with vomiting, when this was not being undertaken by the patient.
(iv) We generally feel that Dr B's note keeping was not comprehensive enough.
(v) We do not feel that it was the responsibility of Dr B to educate Miss J, a temporary resident, consulting when she was not feeling well, on the management of diabetes.
Appendix B - Glossary of terms
| Technical term | Meaning |
|---|---|
| MODY (Mature Onset Diabetes of the Young) | a form of non-insulin dependent diabetes (first used in paragraph 1) |
| Diabetic ketoacidosis | an excess of acid and ketones - an organic compound - which may be present in the body tissues and fluids, which develops in diabetics when their condition is getting out of control and may indicate approaching coma (paragraph 1) |
| Hyperglycaemia | an excess of sugar [glucose] in the blood (paragraph 7) |
| Cerebral oedema | an excess of fluid in the brain (paragraph 17) |
| Type 2 diabetic | non-insulin-dependent diabetic, whose pancreas has retained some ability to produce insulin but this is inadequate for the body's needs (paragraph 20) |
