Mrs R, a 56-year-old freelance journalist, became aware she had reduced vision in her right eye. She saw her optician who noted that her visual acuity was 6/18 in the right eye and 6/6 in the left eye. Examination confirmed a nasal visual field defect in the right eye with a normal visual field in the left eye. The right optic disc was atrophic but the left appeared normal. Mrs R’s optician referred her to the local ophthalmology emergency unit, where Dr S confirmed his findings and also detected a right afferent pupillary defect, and reduced colour vision in the right eye. He made a diagnosis of right optic atrophy and arranged blood tests to investigate this further.
Two weeks later Dr S received a telephone call from the virology department informing him that Mrs R had tested positive for syphilis. Dr S immediately contacted Mrs R’s GP, Dr L, informing him of the result and the need for urgent treatment.
On the same day, Dr L wrote a letter to Mrs R asking her to book an appointment. His letter said: “Please be advised that this is a routine appointment, and there is no need for you to be alarmed.”
Mrs R did not take this letter seriously and no appointment was made. Dr L did not pursue the matter.
Seven months later, Mrs R was referred to Dr D in the neuro-ophthalmology clinic for deteriorating vision affecting both eyes. Dr D diagnosed bilateral optic atrophy and repeated the blood tests for syphilis. He arranged for Mrs R to be admitted to hospital where lumbar puncture and examination of the cerebrospinal fluid confirmed the diagnosis of neuro-syphilis.
Mrs R was treated with penicillin and corticosteroids, which cleared the infection. Post-treatment visual acuity in the left eye was 6/5 but she had a severely reduced field of vision. In the right eye her visual acuity was light perception only. Although these changes had stabilised, Mrs R was assessed as legally blind.
Mrs R brought a case against her GP alleging that the delay in treatment led to her losing her sight. Due to this she had lost her driving licence which substantially reduced her earning capacity.
Expert opinion
A GP expert considered that in failing to follow up on an important laboratory result, Dr L was in breach of his duty of care. Ophthalmology expert opinion concluded that the delay in treatment resulted in loss of the remaining 50% of vision in the right eye and 80% of vision in the left eye. The loss of sight impacted substantially on Mrs R’s lifestyle and earning capacity. Both the virology department and the ophthalmologist were deemed to have acted appropriately and promptly.
The case was settled for a substantial sum on behalf of Dr L.
Learning points
- When faced with a serious condition requiring urgent treatment you should be diligent in your attempts to communicate this to the patient promptly and sensitively.
- When communicating urgent information to colleagues, direct conversations are the most effective. It may be useful to follow a conversation with a letter as this may reinforce a point and prompt further action. A letter on its own may be insufficient in that it may be mislaid, misfiled or the importance not understood.
- When communicating sensitive information to patients a face-to-face consultation is most appropriate. Communicating such information in writing could lead to misunderstanding, a breach of confidentiality, or may downplay the urgency of the matter.
- Be aware of local practice: the management of neuro-syphilis is often initiated through neurology or medical teams and the ophthalmologist should consider direct referral when the condition is sight threatening. Ophthalmologists should also be prepared to discuss laboratory results with patients and, where appropriate, emphasise the need for prompt treatment.
- In New Zealand it would be unusual clinical practice for a GP to be requested to take responsibility for treatment in this situation. However, if the handover of care had been clear and accepted by the GP, then the GP would bear primary responsibility for not taking action.