Annex A to Chapter 2 - Investigations
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Case No. W.125/97-98
NHS Independent Review Panel
Independent Review - Mr J
Regarding the Late Miss J
DATE OF PANEL - 6 JANUARY 1998
Terms of Reference
To investigate the facts and reach conclusions on the following:
1 Whether Dr B, knowing that the late Miss J was a diabetic, observed proper professional standards in dealing with her on the 19 July 1997.
2 Whether he kept an accurate record of the consultation on the 19 July 1997.
1. The Panel was convened on 18 December 1997, following formal complaint by letter from Mr J, brother of the late Miss J, dated 13 November 1997. The Panel was convened, after consultation with the lay Chairman.
2. The Terms of Reference had been agreed with Mr J and were:
To investigate the facts and reach conclusions on the following:
1. Whether Dr B, knowing that the late Miss J was a diabetic, observed proper professional standards in dealing with her on 19 July 1997
2. Whether he kept an accurate record of the consultation on 19 July 1997
Membership
3. Panel members were:
Chairman
Convener
Independent Review Panel Member
Clinical Assessors were:
GP1
GP2
Evidence
4. Written evidence, consisting of correspondence and Dr B's clinical notes, totalling 12 pages, was made available to all members, assessors and parties before the hearing, which took place at H M Stanley Hospital, St Asaph, Denbighshire at 9.30am on Tuesday, 6 January 1998.
Evidence in person was heard from:
Mr J, Fiancé of the late Sarah Jane
Dr B - General Practitioner
Dr G - as friend to Dr B representing the GMC
5. Prior to the hearing, Mr J had made available to Panel Members a comprehensive bundle setting out the history of the case, totalling 39 pages, with appendices of diabetic treatment and protocol, together with extracts from medical journals explaining current medical opinion on the subject. Much of this material was not germane to the Panel's Terms of Reference, but it provided useful background information and enabled the Panel to consider the Terms of Reference within a whole picture.
6. The evidence given by Mr J was supported by a 20 page written statement made available to the Panel at the hearing.
Agreed Facts
7. Miss J died tragically in her 21st year on 31 July 1997 when life support was terminated following collapse on 23 July 1997. Cause of death was certified as "acute cerebral oedema" and "diabetic ketoacidosis".
8. On 12 July 1996 Miss J had been diagnosed as MODY i.e. Mature Onset Diabetes of the Young. At this time Miss J was aged 19 years and four months. Such condition would not require administration of insulin and would thus be described as NIDDM, or type two diabetic, as opposed to IDDM or type one diabetic.
9. The Panel received evidence, confirmed by both Clinical Assessors and by Dr B, that MODY is an extremely rare condition. Both Clinical Assessors have been in practice for many years but neither had come across a case. Dr B gave evidence that he had heard of it at Medical School and had one obese patient with the condition.
10. The Panel accepted as fact that it is unlikely that a young person with diabetes would be NIDDM.
11. The Panel therefore concluded that, in fact, Miss J was probably not NIDDM but that, even if she had been, her condition would require utmost care and control. This opinion is based on evidential probability and on the tragic outcome of Miss J's case. The circumstances of the diagnosis as MODY are beyond the Panel's Terms of Reference.
Holiday Centre
12. Miss J arrived at the Holiday Centre, accompanied by her Fiancé, on Friday, 18 July 1997. Records indicate that she had been feeling unwell before her journey. Her fiancé gave evidence that, during the evening and night of 18 July, Miss J was "actually sick a number of times".
13. She continued to feel unwell and attended the Surgery at the Holiday Park at 4.00pm on Saturday, 19 July, accompanied by her fiancé. There were other people attending the Surgery - evidence indicates their number as two.
Surgery
14. The Surgery is held at the Holiday Park.
Hours are displayed prominently at the Surgery and are:
Monday - Friday 12.30pm -1.00pm
Saturday & Sunday 4.00pm -4.30pm
Nurse on duty
Monday - Friday 10.00am -4.00pm
Emergencies - contact security
15. Whilst hours appear to be minimal Dr B stated in evidence that they were adequate since most people who come on holiday were in good health. Those that were not tended to stay at home. Saturdays were particularly quiet since Saturday appears to be changeover day.
Dr B
16. Dr B is a General Practitioner having qualified at a London teaching hospital. He has been in general medical practice for some 12 years and is Senior Partner of three in his current practice. The Practice has approximately 5,000 patients and the work at the Holiday Park, where there are 1000 caravans (approx.) is undertaken during the holiday season.
Consultation on 19 July 1997
17. Miss J was seen by Dr B at between 16.15 and 16.30 hours on Saturday, 19 July 1997. On arrival at the Surgery she had been asked to complete a visitor form. The form appears to have been completed by Miss J and there is no evidence that she was actually sick during her visit to the Surgery.
18. Evidence was received from Miss J's fiancé that he attended the consultation with Miss J. Dr B was not certain about this, could not recollect it, and did not "see it as an issue". The Panel therefore accepted that the fiancé was present at the consultation.
Examination
19. The Panel found that Miss J indicated to Dr B that she was MODY. This is evidence from Dr B's notes of the consultation and he recalled the fact since it was so unusual.
20. Miss J also informed Dr B that she had been vomiting for the last two days, but Dr B indicated that she was not sick during the surgery visit.
21. Dr B gave evidence that Miss J appeared to be a healthy young woman, and discussed Miss J's testing for blood sugar with her. She indicated to him that she had not done a test. Dr B did not test specifically for diabetic control.
22. The Panel found that Dr B did not consider hyperglycaemia nor diabetic ketoacidosis. He examined Miss J for appendicitis and gastritis and formed the opinion that she was probably suffering from gastritis.
23. Accordingly he prescribed Maxolon, an anti-nausea medicine, and as is standard practice asked Miss J to return the next day if she were no better.
24. The Panel found that Dr B had no access to Miss J's Medical Records and did not make enquiry into the detail of her medical history. He did state that there was no smell of ketones on her breath, detectable during the course of his examination, but he did not specifically make this test and did not record anything in the medical notes.
25. It appears that the examination carried out by Dr B was based on his observation that she appeared to be a healthy young woman. He did not consider it necessary to arrange admittance of Miss J to hospital.
26. Miss J left the Holiday Park early on Sunday, 20 July 1997, having continued to be unwell. She was seen by her GP at 10.45am on that day.
Conclusion
27. Dr B knew that Miss J was diabetic and had been diagnosed as MODY. He also knew that this was extremely unusual and that he only had one case, where the patient was obese, which Miss J was not.
28. Dr B made no tests specifically geared to Miss J's diabetes but proceeded on the basis of suspected gastritis.
29. Dr B did not make an examination in depth on 19 July 1997.
Records
30. A copy of notes of Miss J's consultation with Dr B was made available to the Panel.
31. The NHS temporary services record appears to have been completed in a mature and firm hand by Miss J but there was a discrepancy in the spelling of her Christian name.
32. A note was also made of the name of Miss J's GP, and of his address.
33. The clinical notes indicate
(1) that Miss J had been vomiting for the last two days out of seven.
(2) that she was MODY
(3) that her abdomen had been examined and appeared normal
(4) that her bowels had been reported as open
(5) that she had been prescribed Maxalon.
34. Other notes had been made but these were not considered relevant, since they had been made after notification of Miss J's death by her brother.
35. The notes make no reference to any other findings, nor of any negative ones which would be relevant when considering problems specific to diabetes. Thus no reference is made to the absence of a smell of ketones on Miss J's breath, nor any other negative indications.
36. The form appears to have been signed and dated by Dr B.
Conclusion
37. The Panel found that the notes did record certain findings and the prescribed medicine. If they are a true record of the consultation then they would indicate that 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.
38. If they do not record relevant negative findings which were drawn by Dr B then we conclude that they would fall below the requirements of good practice.
39. This finding is consistent with the expert evidence of the Clinical Assessors, whose Reports are attached verbatim.
CHAIRMAN
21 January 1998
Independent Review Regarding The Late Miss J :
6 January 1998
40. The review panel was asked to consider:-
1. Whether Dr B, knowing that Miss J was diabetic, observed proper professional standards in dealing with her on 19 July 1997.
2. Whether Dr B kept accurate records of the consultation.
41. It was very obvious that Mr J, the complainant, was still grieving and had not come to terms with the death of a dearly-loved sister. He had done a great deal of research into diabetes and the factors leading to her death. Both the quantity and quality of his research were recognised, but some of his conclusions were open to different interpretations.
The Consultation
42. Dr B's recollection of the consultation between himself and Miss J differed from the account given by Miss J's fiancé, who said that he was present during the consultation. Dr B said that Miss J had waited about 20 minutes in the waiting room without obvious discomfort. She had filled in the Temporary Resident form clearly and legibly, a factor which he considered to be an indication that she was not too distressed physically. He said she told him she was a diabetic - MODY (which is controlled by diet alone) - and that she had been vomiting off and on for 2 days. He said that he examined her abdomen. He did not notice any smell of ketones on her breath. He asked her questions about her condition. He elicited the fact that she had not tested her blood sugar recently and that she never tested her urine. He was satisfied that Miss J was only slightly unwell.
43. He felt that given his findings he treated her appropriately and he told her to make contact the next day if she became worse.
44. Her condition worsened during the night of 19 - 20 July and she felt that return home was her best option. It seemed that while Miss J was not very ill when she saw Dr B, her condition deteriorated after she left the camp.
45. It is good practice to check blood sugars and/or urine of diabetics who are ill. A simple urine test can be a guide to the seriousness of the condition and to whether other tests should be carried out.
The Record
46. The Panel felt that Dr B's record of the consultation was accurate but not very helpful. There was very little history, nor were all the symptoms or examination findings recorded.
47. Keeping accurate records is of prime importance in good practice. The recording of negative findings, probably diagnosis and future management should, where possible, be included.
Report of the Independent Assessor - GP1
The report should be read in conjunction with the Terms of Reference.
48. I carefully read what Mr. J submitted in his letter and also took into account his verbal deposition.
49. I also had the opportunity to read through the letter submitted by Dr B and carefully noted what he had to say during the interview.
50. My conclusions are as follows:
1. There are only scanty details of the presenting complaints and examination in the note.
2. No record about the smelling of breath for "Ketone or Fetor".
3. Dr. B failed to take and enter family history.
4. No record of advice regarding diet in view of the vomiting.
5. No record regarding the enquiry of her blood test.
6. No record of advice to do the test regularly.
7. Dr. B carried out necessary examination and came to a reasonable conclusion after considering acceptable differential diagnosis.
8. Treatment provided was adequate.
9. The record keeping appears to fall below the level of good practice regarding the points mentioned above.
