When nephrologist Dr L faces a claim, we defend it all the way to a trial. By Peter Mordecai, Claims Manager, Medical Protection.
Patient K presented to consultant nephrologist Dr L with a history of pseudoseizures and reflux oesophagitis. An examination was performed where Patient K was noted as having a low-grade fever, oedema of the limbs, and a tender abdomen. Dr L diagnosed Patient K with an infection.
Patient K returned to Dr L the next day and informed them that they were also experiencing lethargy and lower limb discomfort and swelling. They informed Dr L that the symptoms were making it difficult for them to mobilise. Dr L therefore decided to perform a number of tests including autoimmune profiling. This came back with moderately positive anti-cardiolipin Ig G antibodies. Dr L decided to perform a skin biopsy two days later. The biopsy was reviewed and the specimen was consistent with scleroderma. Dr L therefore prescribed cellcept (mycophenolate mofetil).
Patient K returned to Dr L two months later informing them that their symptoms had worsened and that it was extremely difficult to mobilise due to the joint aching, stiffness and fatigue. Dr L decided to perform a second skin biopsy, which came back with the same conclusions as the first biopsy. Dr L therefore changed the prescription to rituximab.
Patient K’s symptoms did not improve and therefore they sought a second opinion, where they were diagnosed with chronic pain syndrome with elements of fibromyalgia and reflex sympathetic dystrophy.
Patient K brought a claim against Dr L alleging that:
- There was a failure to take a sufficient medical history
- There was a failure to conduct sufficient examinations
- There was a misdiagnosis of scleroderma
- Patient K was prescribed immunosuppressants incorrectly
- There was a failure to refer Patient K to a rheumatologist
- There was a failure to obtain informed consent.
How did Medical Protection assist?
Dr L did not have any knowledge of a potential claim until they received a writ of summons and statement of claim. Upon receiving this Dr L contacted Medical Protection who immediately instructed local panel solicitors to file a defence on behalf of Dr L.
In addition, Medical Protection instructed the panel solicitors to obtain Patient K’s medical records and a witness statement from Dr L. The evidence was reviewed internally by Medical Protection’s claims manager and medicolegal consultant, who agreed that further evidence was required. Medical Protection therefore instructed panel solicitors to obtain an expert report from a consultant rheumatologist. The expert supported Dr L’s diagnosis of the scleroderma and that the treatment was not unreasonable.
In order to support Patient K’s position, their legal team produced an expert report from a consultant rheumatologist who took the position that:
- Patient K’s symptoms did not correlate with a diagnosis of scleroderma
- Patient K should not have been prescribed the immunosuppressants
- Patient K should have been referred to a rheumatologist.
Upon receiving the report, the content was discussed with our expert. He agreed that whilst symptoms were not suggestive of scleroderma the biopsy results were definitive in their conclusions and therefore the diagnosis was correct. In addition, whilst the expert agreed that a rheumatologist should have been involved in Patient K’s care, the expert accepted that Dr L had some experience of managing the condition and the medication prescribed. The prescriptions were therefore reasonable and did not result in any harm to Patient K.
Medical Protection assessed the evidence and proceeded to defend Dr L at trial.
Outcome
The judge heard the conflicting evidence from the medicolegal experts and concluded that:
- Dr L was not negligent in the diagnosis of Patient K
- Dr L was not negligent in prescribing cellcept and rituximab for the treatment of scleroderma for Patient K
- Patient K did not suffer any pain and suffering as a result of taking cellcept and rituximab prescribed by Dr L.
Despite conflicting medicolegal expert evidence, Medical Protection were successful in defending Dr L in this matter.
Learning points
- Always consider whether it is appropriate to involve a colleague from another discipline of medicine. In this case both experts agreed that a rheumatologist should have been consulted; however, our expert agreed this omission did not cause any harm to Patient K.
- Explain within your medical records the reasoning for your differential diagnosis or suspicions and your strategy going forward. In this case both experts agreed that the symptoms were not suggestive of scleroderma; however, Dr L suspected an autoimmune condition and implemented a strategy to investigate their suspicions.
- Explain within your medical records how the test results are feeding into your differential diagnosis. In this case the moderately positive anti-cardiolipin Ig G antibodies enhanced Dr L’s differential diagnosis of an autoimmune condition and led to the skin biopsy.
- When a diagnosis is made consider whether it accounts for all the patient’s symptoms. In this case Patient K not only had an autoimmune condition but also chronic pain syndrome with elements of fibromyalgia and reflex sympathetic dystrophy.
- With any diagnosis and prescription make sure you are comfortable managing them and any potential issues or side effects that might arise.
New Zealand perspective
This case would be decided at the HDC rather than the courts. When commencing an investigation, the HDC generally asks a question like “did the health professional provide an appropriate standard of care?” Usually, the expert would come from the same discipline as the health professional, and it would be very likely that a rheumatologist in New Zealand providing an expert opinion would come to the same conclusion as the experts in this case, that a patient presenting with significant joint symptoms ought to be reviewed by a rheumatologist. If the expert considered that not doing so was a moderate to severe departure from expected standards, then the nephrologist would be likely to be found in breach of the code. Based on the pattern we observe from the HDC this would be very unlikely to result in disciplinary proceedings through the Health Practitioner’s Disciplinary Tribunal, and the nephrologist would be asked to provide an apology and to upskill in the clinical areas of concern.