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Empowering Patients: Volume 2

Posted on February 7th 2018

Our guide to empowering patients describes how you can help your doctor to help you, by keeping accurate records. We stress that patients, generally, are at a disadvantage in proving what happened when things go wrong. This is because patients cannot control what medical staff write about them in their records and they do not have the opportunity to correct mistakes.

A recent case where a doctor failed to diagnose a patient’s fractured hip stresses this point even further. The subsequent medical negligence case was not successful, partially because there was no accurate record of the initial call. This makes it clear that patients should be recording full details of every telephone conversation they have with medical staff. This is because medical mistakes can happen at any stage of the process, from when you initially contact your GP surgery, all the way to getting appointments in hospital. However, at any stage, there must be clear evidence of these mistakes for a medical negligence case to be viable.

What happened in this case?

In this case, it was alleged that a GP had breached their duty of care by failing to arrange an x-ray to diagnose a patient’s fractured hip during a telephone call.

The patient had multiple sclerosis and walked with a frame. Whilst taking a bath, she had fallen but was able to get up and walk with a frame with her carer’s assistance. She called her GP, and told them that she could walk with a frame but had pain in her leg and bottom. The GP asked if one leg was shorter than the other (which would suggest a hip fracture) and the patient replied that she could not straighten her leg.

In response, the GP advised that she take over-the-counter medication and call again if things got worse. The GP did not think it was necessary to examine the patient. Two weeks later the patient was admitted to hospital and diagnosed with a fractured hip. As a result, she had to have a partial hip replacement.

The Court Case:

When considering if the GP was negligent, the patient’s medical expert said that, since the patient could walk, it would appear that a hip fracture was unlikely. However, because the patient was middle-aged and had fallen she should have been seen by a GP that day because osteoporosis and the resulting fracture was a big risk.

In response, the GP’s expert stated that a person generally could not weight-bear if they had fractured their hip and that since the patient had multiple sclerosis and did not have full mobility anyway, one would only look for very serious pain.

The judge found that the GP’s conduct had not fallen below the required standard. He stated that the patient’s presentation was consistent with a soft tissue injury as she was able to walk with a frame. He said that she had made no specific complaint of the loss of her mobility and her reported level of pain was not significant. The claim was therefore dismissed, as was the subsequent appeal of the patient.

The Judge’s findings demonstrate the need for patient-kept records:

The judge’s findings only relied on limited evidence. For example, he inferred that the patient’s pain levels were low because she did not take prescription drugs. The content of the first call to the surgery was not used as evidence at all. The judge said that, quite understandably, the GP could not remember the questions she had asked during the triage call and the patient was not asked what questions she had been asked either. If the patient had a record of the questions asked, it may have completely changed the outcome of this trial, as this could have been submitted as evidence.

How can you maintain good records?

There are multiple ways you can keep records of your medical appointments. This can be over the telephone, as above, or in face-to-face meetings. Of course, keeping a record can also help you remember important details about your medication, diagnoses, and treatment in general.

You can keep records by:

  • Making notes during medical appointments and telephone conversations.
  • Asking that copies of any emails or letters regarding your care are copied to you. You can ask for this to be done for all future letters by going to your GP’s reception desk.
  • Sending your Doctor Emails or letters clarifying your symptoms before any appointment (and keeping a copy).
  • Taking photographs of any injuries or concerning moles/wounds you have. You can help to demonstrate the size of a wound, mole, or mark by placing a 20p coin next to it, so it is visible on the photograph.
  • Recording your appointments via video or audio recording. You may be able to do this using your mobile phone. We would advise that you always let your doctor know that you are recording your conversation together.

To learn more about how you can help your doctor to help you, please click here to read our empowering patients guide.

How can we help?

If you believe that you have been the victim of medical negligence and would like to discuss a possible claim, you can contact one of our team by filling in our contact form. Alternatively, call 01244 354688, free of any obligation.

Call and speak to a lawyer on 01244 312306