Introduction
This claim arose from a consultation with the defendant general practitioner on 29 December 2016, at which Dr. Gaynor diagnosed a haematoma of the right groin. In fact, the patient had an abscess which, a few days later, progressed to necrotising fasciitis necessitating amputation of the right leg at the hip joint. It was alleged that Dr. Gaynor was negligent in failing to refer the patient to hospital for further investigations.
Detail
The defendant had become a GP in 1991 and, in 1995, he established a group practice, the main purpose of which was to provide care for university students, homeless people and drug addicts. He therefore had considerable experience at the time of this consultation. KC was an intravenous drug user. Four days prior to the consultation she had missed the vein when injecting and had been in great pain since.
KC was not a registered patient, but attended a weekly walk-in clinic. She maintained that her groin was bright red and “hot as a kettle”. In oral evidence she described the examination as brief and asserted that the doctor just wanted to move on to the next patient.
Dr. Gaynor had never seen KC previously but had access to her electronic medical records. He examined her, including listening to the chest with a stethoscope which might have indicated an infection. He checked the patient’s temperature and pulse, but both were normal. He noted a large haematoma, the size of a fist, on the upper right thigh. It was not hot. However, examination of the leg was normal and there was no evidence of trauma, poor blood supply or clots. His view was that KC had punctured either the femoral vein or artery and might have impaired clotting stemming from liver damage owing to previous issues with alcohol. He considered abscess as a possible diagnosis but felt this was unlikely because the patient did not have a temperature, was not generally unwell and the site was not warm to touch nor red or inflamed. He therefore considered that the presentation was haematoma, which was the cause of her pain. He gave painkillers rather than a prescription for antibiotics and advised KC to go to hospital if there was any deterioration (the practice was due to be closed over the New Year period).
The computer system revealed that KC had been called into the appointment at 15.11 and the next patient was called at 15.33, so the consultation would have lasted approximately 20 minutes, which is double the standard period.
Dr. Gaynor was cross-examined over his diagnosis and why he did not refer the patient to hospital. He maintained that if GPs refer every slight suspicion of a condition for further investigation, huge numbers of people would be sent to hospital.
The GP expert witnesses disagreed fundamentally on whether Dr. Gaynor had acted appropriately. Judge Howells described them both as experienced and respected in their field, but thought the claimant’s expert had underplayed the examination findings of no raised temperature, redness or tachycardia. She had some sympathy with the argument that Dr. Gaynor should not have excluded abscess, and described both experts’ views as “apparently logical”.
Decision
KC was doing her utmost to recall a brief consultation some six years previously, but her recollection was imperfect.
It was a fundamental feature of the Bolam test that a medical practitioner is not to be found negligent if he/she acted in accordance with a practice accepted as proper by a responsible body of medical practitioners at the time. The defendant’s GP expert, Dr. Cameron, completely supported the course adopted by Dr. Gaynor. The decision not to refer was logically reached, and the advice on possible follow-up was reasonable. Dr. Cameron’s view represented a reasonable and responsible body of professional opinion. The defendant was “a caring, competent GP who took an entirely reasonable course in terms of his treatment of the claimant. He was not negligent”. Consequently, judgment was entered in favour of Dr. Gaynor.
Comment
Although the diagnosis was wrong, the defendant had not been negligent in reaching it. This is, in many ways, a classic demonstration of operation of the Bolam test in practice. Unquestionably the consequences for KC were devastating, and therefore it is unsurprising that a claim was made. However, it would be quite impractical for GPs to increase significantly the numbers of patients they refer to hospital, even ignoring present circumstances in the NHS. The law does not judge actions of clinicians from the perspective of how serious their consequences were, but rather upon whether those actions would have been supported by a responsible body of clinicians at the time, and whether that opinion was logical.
