Case 37 A woman told off for ignoring her friends

Jayne was aged 46 when she initially consulted Dr Saad. She had been to the optician the day before because she felt her vision had deteriorated. She had been told off on a few occasions by friends who said that she had ignored them. She had not noticed, or not seen them, as they walked past in the street. The optician had suggested that she see her general practitioner and get referred to hospital.

What would you do now?

Dr Saad measured Jayne’s visual acuities. They were normal. Her fundi also appeared normal. Dr Saad was familiar with the optician. The optician was an anxious professional who often sent patients to Dr Saad. Dr Saad reassured Jayne that he could find nothing particular wrong and that referral to hospital did not seem necessary. He suggested review if the problem got worse.

What would be your differential diagnosis and how would you discriminate between them? Would you have done anything else?

Two days later the letter arrived from the optician. An automated field test had showed black squares in the upper outer quadrant of the right eye field and a lesser number of black squares in the right field of the left eye. Dr Saad was not familiar with the printout from the test but the optician suggested non-urgent referral to hospital. Dr Saad decided to refer Jayne for an ophthalmology opinion under the Choose and Book system.

Six months later Jayne consulted Dr Fowler at the practice. She had been experiencing daily headaches for several weeks. They were dull, tended to be worse in the morning and were largely gone by lunchtime. She had also noticed that she seemed to be a bit clumsy when she had the headaches and had been bumping into things.

Dr Fowler did not notice the ophthalmology referral 6 months earlier. It appeared subsequently that Jayne had not known what the Choose and Book letter she was sent was about, and she had taken no action. Jayne’s blood pressure and fundi were normal but Dr Fowler thought that Jayne was not seeing out of the lateral field of her right eye. He questioned Jayne about flashing lights (she had had none) deliberated about whether to refer her to neurology or ophthalmology and decided on the latter. He also started her on low-dose pizotifen.

Unfortunately, before she was seen in the ophthalmology clinic Jayne had a fit while driving and crashed. She was unhurt but the driver of the other car was seriously injured. On examination in it was noted that Jayne had a significant visual sensory inattention in the entire right visual field and a largely homonymous field loss extending to about one quarter of her right visual field.

Investigations revealed that Jayne had a large left occipital glioma. The driver of the other car brought an action against Jayne, and Jayne’s insurance company brought an action against Dr Saad and Dr Fowler on Jayne’s behalf.

Do you think the claim will succeed?

Expert comment

Cases in which a communication between medical professionals goes astray, or is not acted upon, are common. The communication from the physiotherapist or optician fails to reach the general practitioner, or the general practitioner fails to act upon it. It is also important to recognize that colleagues, such as opticians, physiotherapists, osteopaths etc., do have a great deal of experience in their respective areas and that their findings of something being out of the ordinary or abnormal should be taken seriously.

In this case there were a number of communication breakdowns. The letter from the optician did not reach Dr Saad until after he had seen Jayne. He then did not communicate his decision to refer her to Jayne herself. Dr Fowler failed to read back in the notes and notice Dr Saad’s consultation and the subsequent referral. When significant medical errors occur there is often a concatenation of minor errors that lead to, and contribute to it.

Assessing visual field to confrontation is not a particularly easy skill for a general practitioner and it does require significant care. Ideally each eye should be examined separately with a small object (preferably red – traditionally a hat pin but a red biro top will do!) and then fields should be checked more grossly (wiggling index fingers) with both eyes open. As with many neurological examination skills, general practitioners do not frequently use them and quite often cease to practise them at all. The sad thing with this is that these are proven and useful examination techniques, they cost nothing, and if they are not used, the skill atrophies.

It is also important to recognize the limitations of examination findings and the performance characteristics of tests. A unilateral sensory inattention (stimulus detected on one side when unopposed but extinguished with bilateral stimuli) is quite a difficult sign, but an automated visual field test is very sensitive at detecting field loss. Dr Saad admitted that he was not really familiar with the test or the meaning of the printout he was sent.

Dr Saad should really have sought clarification from the optician, an online textbook or a specialist if he was uncertain about the significance of the field test. The decision to refer Jayne should really have been communicated personally to her. It was predictable that she might be unsure about the ‘Choose and Book’ letter and not ring to make the necessary appointment.

Dr Fowler should really have looked back at the earlier notes and correspondence. As compared to hospital practice, general practice is characterized by 10-minute consultations about diffuse and multiple matters but the general practitioners, individually or (more commonly now) collectively, build up a large amount of information about a patient over the previous year or years. It is essential to use this resource if the 10-minute consultation is going to be more than a snapshot glimpse of the patient.

Many negligence cases hang on the question of whether the general practitioner should have glanced at the previous notes (usually they should have glanced at a few) or the summary of the past medical history and current drug therapy (almost invariably they should have done so).

The difference between homonymous binocular visual symptoms and uniocular symptoms is an important one. For example right visual field flashing lights are usually occipital in origin and are probably migraine. Flashing lights in the one eye are usually retinal in origin and generally indicate traction due to a posterior vitreous detachment or retinal tear. These are important distinctions and they occur frequently in patients presenting with visual symptoms.

Headaches in isolation are the presenting feature of cerebral tumours in only 2–16% of primary cerebral tumours, and are the cause of headaches in only about 0.1% of all consultations about headache (Hamilton & Kernick, 2007). Most cerebral tumours present with a fit. About 1.2% of patients in general practice with a first fit have a tumour as the cause (Hamilton & Kernick, 2007). Case control studies have not shown that headache on waking is a particularly useful clinical feature to predict a cerebral tumour.

It would not be possible to defend breach of duty on behalf of Dr Saad. A competent general practitioner did need to recognize the significance of the homonymous (non congruent) field defect reported to him and refer urgently for a neurology opinion/head scan. It was also necessary to ‘safety net’ by notifying the patient directly.

Dr Fowler’s actions would also not be defensible on breach of duty because he should have looked at the earlier clinical note, recognized that the field defect was homonymous and referred urgently for a head scan or neurological opinion.

Legal comment

Neither Dr Saad’s, nor Dr Fowler’s standard of care can be defended. If this was Jayne’s claim, then a neurosurgeon would be called on to comment on whether referral 6 months previously would make any difference to her outcome. But that is not the question that is posed. The claim comes from the driver of the car who was injured in the accident.

With appropriate referral, the glioma would have been diagnosed well before the fit and treatment may have postponed the deterioration. But there is a more fundamental point. People suffering from a medical condition are under a duty to report the condition to DVLA, if it affects their ability to drive. If the condition had been diagnosed earlier, Jayne would have received advice from her doctors and she would have surrendered her driving licence. In her condition, she should not have been driving and the blame for the accident must, therefore, lie at the door of Dr Saad and Dr Fowler. Their MDOs will have to compensate the injured driver.

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