CEGPR case studies and Significant Event Analysis exemplars

A brief outline of the case and history

This patient is a 39-year-old man who returned to live in Australia after two years living in Ireland. He returned after the relationship with his partner broke up. His partner and their then four-year-old daughter remained in Ireland. He is unemployed and last held down regular employment as a hospital porter several years ago. He lives alone in rented accommodation but has family living nearby who are socially, emotionally and financially supportive. A family member often accompanies him when he attends our medical centre.

His current medical problems include:

• Chronic drug addiction (Benzodiazepines regularly and frequent use of cannabis)
• Chronic alcohol dependence
• Depression, anxiety and post-traumatic stress disorder (related to previous experience in the armed forces) - currently under specialist management with a consultant psychiatrist
• Obesity
• Asthma with frequent exacerbations
• Psoriasis

His past relevant medical problems include:

• Previous seizure induced by alcohol withdrawal resulting in head trauma with subdural haemorrhage
• Previous episode of alcoholic pancreatitis

His current social problems include:

• Social isolation
• Unemployment
• Unwanted separation from his daughter
• Previous history of doctor/prescription shopping

Personal reflections on the case

When I first met this patient, it was difficult to form a therapeutic relationship with him, partly because of his demands for prescriptions which could easily lead to confrontation. However, over the last couple of years, we have got to know each other better and a level of trust has developed. He attends frequently and prefers to see me rather than one of the other doctors in the practice.

One of the particular challenges for me has been the level to which I am willing to acquiesce to his requests for medication to help maintain the relationship. This has required delicate but firm handling to avoid any degree of collusion. We ultimately came to an agreement that has formed a kind of unwritten contract between us in that I will supply prescriptions according to the agreed plan (also known to his consultant psychiatrist) and in return for this I make sure that he has access to me personally unless I am away from the practice. Another challenge has been to remain patient and to be grateful for small improvements. Nevertheless, we have made some progress.

Since his last admission to a private hospital for detoxification nine months ago he has not touched any alcohol. His mental state has improved markedly with less depression, lower anxiety levels and better relationships with his immediate family who remain extraordinarily supportive. He recently applied for work as a delivery driver and has undertaken some voluntary work at the local day centre but has yet to secure regular employment. He no longer shops around for doctors willing to prescribe for him.

I have had to learn a lot about the management of drug addiction and alcohol dependence while managing this patient. I have also learnt a lot about myself, not least the tendency to make hasty judgements when first meeting patients based on insufficient information. Although his behaviour can be challenging, he has also had considerable adverse life experiences that resulted in a downward spiral and but for the help he continues to receive from his family, the outcome could easily have been a lot worse.

We have also had to learn and adapt as a practice. Some of my partners still find him a little intimidating and some tend to make him feel as if he is being “told off” if he attends for a prescription. One of the issues is that he finds any disruption to his routine destabilising and this manifests itself in behaviours that are easily interpreted as aggression.

We have therefore devised an agreed plan between us such that if I am not going to be available, I try to notify him in advance so that there are no surprises. We have also agreed that if I am unexpectedly unavailable, he will be seen by one of two other doctors who know the case well enough and are willing to provide his agreed supply of medication, but no more.

One of the other key learning points for me has been the benefit of thorough record keeping, especially when detailing prescription plans. Also, it has been very helpful to make sure everyone dealing with this patient knows the plan, including a nominated pharmacist. This has been time-consuming to set up but has saved a lot of problems in the long run.

Finally, I have reflected that this patient has been extremely fortunate to have such a supportive family. Without their help, he would not have been able to be admitted to a private hospital for his alcohol detoxification and he would not have received such good care through the public system, particularly in terms of access to inpatient and outpatient specialist treatment. Although our health care system has many strengths, equality of access based on clinical need rather than the ability to pay sadly remains some way off.

A brief outline of the case and history

This patient was an 80-year-old retired company director.

I only met this patient for the first time after the death of his wife. He was grieving and part of his distress was due to his difficulty in coming to terms with his perception that his wife had been misdiagnosed (by a different doctor) with asthma when in fact it later came to light that she was suffering from lung cancer.

The patient came to see me because I was the GP who finally detected his wife’s cancer. She had been suffering from shortness of breath for several weeks and the treatments she had been prescribed for presumed asthma had not been helping. A chest X-ray was reported as normal so, given the persistence of the symptoms I requested a CT scan. It was the scan that ultimately revealed the true diagnosis. I referred her for specialist treatment but, sadly, not long after treatment commenced, she passed away suddenly due to pneumonia that failed to respond to treatment.

I listened to his concerns and it appeared to me that he was, amongst other things, concerned about his health. Therefore, I offered to perform a health check for him. Part of his health check included a blood test which showed impaired liver function and thrombocytopaenia. I organised further liver investigations with ultrasound and CT scan, which showed evidence of hepatic cirrhosis with chronic pancreatitis and evidence of portal hypertension. Although the patient was clinically well at this point, given the serious nature of the investigation findings, I referred him for an opinion from a hepatologist.

The patient underwent gastroscopy which showed large gastric varices and the patient was referred by the hepatologist to a tertiary hospital centre for multidisciplinary team care. He was diagnosed with rapidly progressive hepatocellular carcinoma which was invading deeply into the portal vein and the inferior vena cava and therefore unamenable to treatment by surgery or radiotherapy. The cirrhosis also meant that systemic treatment with chemotherapy would pose a high risk of liver decompensation.

Therefore, the only realistic treatment available was palliation but the patient found this very hard to accept, particularly because he still felt clinically well and of course he was still struggling to come to terms with his bereavement. I saw him in the presence of his son, listened to his concerns and understandable anxieties before discussing what the palliation might mean.

Not long later, the patient began to deteriorate rapidly with abdominal swelling combined with considerable weight loss. I arranged a review by the hepatologist to manage his ascites. I also initiated a palliative care referral. I provided my direct contact number to the patient and his son in case of emergency but sadly the patient died soon after in the local hospice.

Personal reflections on the case

There are several points of reflection on this case:

1. It is important not to be unduly critical of colleagues when there might have been an oversight or even an error of judgement. Often we don’t have access to all the facts and we were not present when the patient consulted our colleague. Everything becomes clearer in hindsight. In this case, listening was a very important part of the management and I simply listened to his concerns regarding his perceptions about his wife’s diagnosis.
2. Responding to patients’ concerns is important. In this case, it was a response to the patient’s understated concerns about his health that prompted the investigations that uncovered his diagnosis. I might not have suggested the health checks, but I am glad I did and would do so again in a similar situation. Ultimately, this made no difference to the progression of his disease but it did help him to trust me, whereas his faith in the medical profession had diminished with his experience of his wife’s illness and subsequent death.
3. The patient was not satisfied with the explanation given by the hepatologist regarding the inability to offer more aggressive treatment. The patient felt that insufficient explanation was given during the consultation and after receiving the news that his cancer was untreatable, he felt lost and confused and there was no further follow up arranged nor was there any referral to palliative care services. Again, listening to his ideas and concerns was important and giving him time and space to express his thoughts was a key factor in developing a trusting relationship.
4. Providing a strategy, even though this fell short of offering a cure, was important. A helpful part of that strategy was the offer of follow up and a number to ring if problems arose.

Continuity of care and a clear plan can often help even in difficult situations where therapeutic options are limited.

In summary, I think there were some important learning points from this case. In terms of what not to do, it was to refrain from criticising colleagues. The importance of listening and responding to patients’ ideas, concerns and expectations is demonstrated and whilst the concern is that this can be time-consuming, it saves time in the long run. This is an area of communication skills that can always be improved on. The coordination of care by the GP is a key element of the task in such cases and the impact this can have on a successful outcome is often underestimated.

What happened - including your role?

A 5-year-old boy attended the practice nurse, accompanied by his mother, after falling off a coffee table earlier in the day.  He had initially complained of pain in his left arm and for a time did not appear to want to use his left hand. The practice nurse was unsure and asked for another opinion. My clinic was fully booked but I agreed to see the child as an extra added on at the end of the morning. By the time I saw him I concluded there was nothing to suggest a fracture and I explained that this was most likely a soft tissue injury but asked the mother to return if she had any further concerns. The management plan was essentially simple analgesia.

The child was subsequently taken to the emergency department because later that day after our clinic had closed, he complained of more pain and was tending not to use his left hand when playing or eating.

When he was assessed in the emergency department an X-ray confirmed a buckle fracture of his left distal radius. He was treated with a below-elbow cast. He made a full recovery and the cast was removed after 3 weeks. However, his mother questioned why a referral for an X-ray was not made at the first appointment.

Why did it happen?

Buckle fractures in young children are common and may present with few symptoms or signs. However, a history of functional impairment could be significant.  In general, these fractures heal well and the use of a cast is mainly for comfort.

What was done well?

The notes from the original consultation do refer to the advice given to the mother to return if she had any concerns. In this sense, a “safety net” was provided. The outcome was good in that the child made a full recovery. The mother’s concerns were acknowledged, an apology was made and she was reassured by the commitment to have the event reviewed.  In this way, we kept our response transparent and the mother did not pursue a formal complaint.

What could have been done differently - and who was involved in the discussion?

A discussion took place between me, the practice nurse, and one of the other partners because essentially this was a missed diagnosis.  The main focus of the discussion was the clinical record made at the original consultation. Although reference was made to the likely diagnosis (soft tissue injury) and the advice to return if there were any concerns was clear, there was a lack of any record of the actual assessment made. I could not recall exactly what assessment I had made at the time. This made it difficult when explaining the sequence of events to the mother who questioned the decision not to ask for an X-ray at the initial consultation.

Regardless of the positive outcome, my clinical notes on this occasion were not at the standard I would have hoped for. In particular, there was no mention of a functional assessment and it's possible that this would have resulted in a different conclusion and management plan.

What have you and the team learnt?

The event took place on a particularly busy day in the practice but this should not be used as an excuse. The most important learning points were:

1. Always have a high degree of suspicion when a child has experienced a fall followed by a period of time when they don’t want to use the injured limb.
2. Always make a functional assessment of an injured limb when possible.
3. Clinical notes should always include the assessment made rather than simply the conclusion.

What changes have you or the organisation made?

In this case, the outcomes were largely personal learning points for me and also for the others present at the discussion who admitted that they also might not have included any details of the assessment made, particularly if there was significant time pressure.

Although in this case the outcome was good and the diagnosis relatively minor, this case was a helpful reminder that it is essential to keep accurate and sufficiently detailed, contemporaneous clinical records.  

What happened - including your role?

A patient made a prescription request over the phone for an item (Ketone test strips) that they had not been prescribed previously. The request was passed to the practice nurse who then passed the request to me as the prescription was for an item not previously prescribed.

The prescription appeared to be reasonable and appropriate, so I signed it but did not realise that it had been issued to a different patient with the same name.

The original patient collected the prescription, but the error did not come to light until the incorrect patient was sent an invoice.

Why did it happen?

The error occurred for three main reasons.  Firstly, too many people handled the request, which increased the possibility of an error.  Secondly, the message was passed by handwritten notes rather than via the clinical system and so the message was not attached to the correct patient’s record.  Thirdly, I did not double-check the details of the patient when issuing the prescription.

Finally, the pharmacy did not double-check the identity of the patient including their date of birth when handing over the prescription.

What was done well?

When the error came to light an immediate explanation and an apology was made to both patients involved.  A meeting was convened to which a representative of the pharmacy was invited.  This was done in a spirit of improving systems to prevent this happening again, rather than in a sense of blaming any one person for the error.

What could have been done differently - and who was involved in the discussion?

The following people were involved in the discussion about this event:

• Practice Manager
• Doctor
• Practice Nurse
• Receptionist
• Pharmacist

It was recognised that there were several opportunities where, if things had been done differently, this situation could have been prevented. In this case, it was fortunate that no harm came to anyone and it was an opportunity to update our systems and procedures to make them better.

1. The practice of accepting prescription requests by phone was reviewed and this was thought to be inherently more likely to result in errors.
2. Messaging needs to be done via the clinical computer system so that messages and tasks are attached to the clinical records of the relevant patient.
3. At all stages, checks should be made to ensure the correct patient is being dealt with.

What have you and the team learnt?

Firstly, we were pleased that the patients responded positively to the team acting quickly once the error came to light. The apologies and explanations were accepted.  We were also pleased that the team came together constructively to discuss how things could have been done differently and how to improve our systems and processes. Several changes were made as detailed below.

What changes have you or the organisation made?

When this came to light it was a shock to me personally.  It was also a relief that this had occurred with a prescription request that was unlikely to cause harm, but it could have been much more serious.  Since then I have personally been much more thorough in checking the identity of patients.

The following changes were agreed and implemented:

1. Phone requests for prescription items are only permitted for previously prescribed items (i.e. repeat prescriptions) and only for those patients where this is agreed and documented as acceptable – this is only a small minority of patients and in all other cases prescription requests should be made online or in writing. 
2. All messages and tasks relevant to a particular patient should be done via the clinical system rather than by hand.
3. All staff to be reminded to check patients’ identities when writing or issuing prescriptions.