Natalie Aprea, Senior Counsel, Norton Rose Fulbright, Australia
Continuity of care is one of the cornerstones of medical practice and the failure by clinicians to ensure continuity of care is a major factor in the occurrence of adverse incidents involving patients and consequent litigation.
Continuity of care is when a patient experiences a series of discrete healthcare events in a coherent, connected and consistent manner in accordance with their medical needs and personal circumstances.
As medical defence lawyers, we repeatedly see clinicians being sued by patients in circumstances where a failure to ensure consistent and connected healthcare has resulted in a patient suffering a catastrophic health event or the delay in diagnosis of a preventable, and often terminal, medical condition. Healthcare practitioners have a duty of care to their patients and have a legal obligation to adhere to a standard of reasonable care. Encapsulated within this obligation are the principles of continuity of care.
It is essential for healthcare practitioners to recognise that a clinician can breach their duty of care by failing to provide connected and coherent healthcare even when consulting with a patient on only a single occasion for a discrete medical complaint or repeat prescription.
Below are two case studies where failures by health practitioners to ensure continuity and follow-up care has resulted in an adverse outcome for the patient and subsequent litigation against the doctors.
Case 1
- Patient A, a 55 year old man, attended a local medical centre on 25 October and consulted with Dr Blue with a presentation of alcoholic cirrhosis.
- Dr Blue examined Patient A and ordered bloods (AFP, TFT, GLU, PR, PSA, ESR. CRP, CEA, MBA, LIP, INS, FBE).
- Patient A’s PSA results were as follows:
- Total PSA: 8.97 ug/L
- Free PSA:0.91ug/L
- Free PSA: Ratio10%
- Dr Blue made the following notation in the patient records “IBx: Prostate Specific Antigen (PSA –Discuss –needs DRE)”
- Patient A returned to see Dr Blue on 3 December complaining of left chest pain radiating to the left arm intermittently for several weeks. Dr Blue ordered a chest x-ray.
- Patient A returned to consult with Dr Blue on 4 December to discuss the findings of the chest x-ray (nothing abnormal detected). Dr Blue did not discuss the PSA results and no DRE was performed.
·Patient A attended the medical centre and consulted with another doctor, Dr Brown, on 6 March the following year for an earache and on 10 April for a blood test in preparation for a consultation with a gastroenterologist. Dr Brown did not include a PSA and did not refer back to the previous blood test and PSA results.
- On 19 June Patient A attended the medical centre and consulted with Dr Brown, for a pain in the hand. Dr Brown ordered bloods, not including a PSA, and imaging. Dr Brown did not refer back to the previous PSA results.
- Patient A consulted with Dr Green on a further six occasions for various health complaints.
- On 17 March the following year Dr Green ordered bloods which included a PSA. By this stage, Patient A’s PSA result was 21.2 ug/L.
This case study highlights the importance of clinicians looking back at past consultation entries (including with other doctors), checking investigations have been performed, reviewing test results and ensuring everything that requires it has been actioned. This duty exists even if it was a different doctor who ordered the investigations or if the patient attended for an unrelated complaint.
Case 2
- Patient B, a 38 year old woman, attended a medical centre and consulted a number of general practitioners over a five month period from January to June. She complained of having experienced chronic headaches for two to three years. Patient B was advised to keep a headache diary and a CT scan of the sinuses was ordered. The CT result showed no evidence of mucoperiosteal thickening, polypoid disease or intercurrent sinusitis.
- Patient B was referred for a plain x-ray of the cervical spine which demonstrated degenerative change in the cervical spine with loss of the normal cervical lordosis. Patient B was referred to a chiropractor and prescribed Valium.
- On 24 March, Patient B consulted Dr White and complained of persisting pounding headaches with nausea, vomiting photophobia and phonophobia. Dr White diagnosed Patient B with migraine and prescribed Imigran tablets.
- On 17 April, Patient B consulted Dr White and complained of wry neck and increase in frequency of headaches.
- On 5 June, Patient B consulted Dr Purple whose consultation note reads as follows:
“dr [endocrinologist]
6/12 tft
Actions:
Prescription printed: Carbimazole 5mg Tablet daily
Prescription printed: Trifeme 28 Tablet 1 Daily
Prescriptions printed: Imigran50mg Tablet 1 Three times prn, for migraine -TAKE AT FIRST SIGN OF A MIGRAINE. Max 6 tabs in 24 hours
- Patient B wanted repeat prescriptions and to discuss her headaches with Dr Purple. Dr Purple said to her “I’m not your doctor. Go and see your regular doctor!”
- Two months later, Patient B collapsed and was taken to hospital. A CT scan reported: Large M1 right MCA aneurysm with likely rupture into right temporal haematoma and extensive subarachnoid haemorrhage.
In this case, Dr Purple declined Patient B’s request to discuss her chronic medical complaint and told her to go back and see her regular general practitioner. In consequent litigation, Patient B alleged that Dr Purple’s failure to treat her headaches was a breach of Dr Purple’s duty of care. A patient sitting in front of a clinician even once becomes that clinician’s patient and therefore the clinician owes a duty of care to the patient.
As these cases demonstrate, steps can be taken in order to assist with the provision of consistent continuous and coherent healthcare in a doctor patient relationship. These steps include:
- Maintaining adequate patient health records, including updating a patient’s medical and family history and assisting with the communication of information among multiple clinicians.
- At every consultation, looking back and reviewing previous patient entries and test results.
- Implementing treatment plans, including any required investigations, management planning and preventative health interventions (including lifestyle advice).
Remember, the duty is on the doctor!!
This information is not intended to be legal advice and as such should not be relied on as a substitute. You may need to consider seeking legal or other professional advice about your individual circumstances as appropriate. Should you wish to obtain further information you can review our Member Handbook Combined PDS and FSG or contact MIPS on 1800 061 113. You may need to consider seeking legal or other professional advice about your individual circumstances as appropriate. Information is current as at the date published.
