Open Access Endoscopy Claim

Case history

Ms M described some obsessive compulsive characteristics and, following a few consultations, the GP prescribed antidepressants. Ms M also had a history of Coeliac Disease which had been diagnosed at age 16 and was managed by diet.

On 29 January 2004 Ms M experienced persistent episodes of severe stomach cramps, vomiting and weight loss and she attended another GP. Ms M was referred to a private specialist for “urgent” endoscopy but did not attend because of financial difficulty.

Ms M continued to experience symptoms of abdominal pain, vomiting and weight loss. After contacting her local GP, an “open access” endoscopy was organised at the Endoscopy Centre, where it was agreed Ms M would be bulk-billed.

On 9 February 2004 Ms M saw the local GP, who completed the standard Gastroenterology Request Form for the Endoscopy Centre. The GP marked the square next to “Upper endoscopy” and under the heading “Clinical Notes” the GP recorded the following:

“Known Coeliac after endoscopy 7 years ago. Over 4kg weight loss, vomiting and abdo pain and some diarrhoea for many weeks.”

The patient was given a document headed “Information Concerning Panendoscopy” and on 13 February 2004 an endoscopy was performed by a gastroenterologist who worked at the Endoscopy Centre one day a week.

At the conclusion of the procedure the gastroenterologist wrote to the local GP and reported that the pharynx, oesophagus and stomach appeared to be “normal”, but the “duodenum still appears abnormal consistent with ongoing villous atrophy”. Under the heading “Summary” the gastroenterologist wrote “persisting villous atrophy”.

Ms M fell pregnant despite persistent symptoms of abdominal pain, vomiting, diarrhoea and weight loss, and successfully delivered a child in January 2005.

By May 2005 Ms M weighed 38 kg and had lost 12 kg. Another gastroenterologist performed a further endoscopy which revealed a small bowel carcinoma.

Medico-legal issues

Ms M claimed damages against both the local GP and the first gastroenterologist.¹ The claim against the GP did not proceed to trial.

The case against the gastroenterologist was essentially comprised of two parts. The precise location of the tumour was in issue. According to some evidence the tumour was located in the third part of the duodenum and according to other evidence it was located at the junction of the duodenum and the jejunum.

In issue was the distance to which the endoscope should be passed to adequately assess the upper gastrointestinal tract. Evidence obtained from two expert witnesses indicated that at the time it was accepted by peer professional opinion that the usual practice was to pass the endoscope only as far as the second part of the duodenum, unless an attempt to go further was warranted by particular symptoms or signs. The Court held that the gastroenterologist was not presented with a set of symptoms strongly indicating the presence of tumour and he had exercised reasonable care and skill in the performance of the endoscopy.

The second issue was the gastroenterologist’s written report which communicated his findings to the local GP. The Court held that the duty which the law imposes on a medical practitioner is a “single comprehensive duty covering all the ways in which a doctor is called upon  to exercise his skill and judgement”.²

Although the open access request required the gastroenterologist to perform an investigatory procedure and did not require him to treat Ms M, the Court held that it was incumbent upon the gastroenterologist to reveal the limitations of his investigations, in case the treating doctor or the patient believed no further investigations were warranted.

The Court found that the gastroenterologist’s written report implied that all of Ms M’s symptoms were explained by villous atrophy. The report did not give the GP an indication that some of Ms M’s symptoms were not explained by untreated Coeliac Disease. The Court held that there was a foreseeable risk that in Ms M’s case a serious condition such as a tumour may exist and despite the “open access” basis for the procedure, the gastroenterologist was obliged to exercise reasonable care and skill to avoid that risk.

The gastroenterologist was found to be negligent for not adequately and fully reporting or advising Ms M and the GP that further investigations and treatment were urgently indicated in this case. The Court held that more probably than not the gastroenterologist’s negligence was causative of Ms M not undergoing further investigations and her tumour being undetected until her second endoscopy in 2005. Damages were awarded.

Discussion and risk management strategies

Open access endoscopy is a widely used and accepted practice. Study results are mixed with respect to reports of potential problems and patient satisfaction. The common problems identified include inappropriate referral and poorly informed less satisfied patients. Many patients prefer to be seen at a specialty clinic before their endoscopy and a British study has shown that additional diagnoses not made by open access endoscopy were made at the clinic visit.³

In Ms M’s case the procedural skill of the gastroenterologist was held to be of a reasonable standard but the quality of the gastroenterologist’s written report was found to be negligent because the gastroenterologist had not adequately communicated the significance of his findings to the treating doctor.

It is important to establish procedures to make open access endoscopy an efficient, safe and reasonable practice. Detailed information about the indications and contraindications of endoscopy should be available to both patients and primary care providers. Mechanisms should be in place to facilitate the endoscopist to receive the patient’s pre-endoscopic information.⁴

A detailed mechanism for reporting results and establishing proper follow-up is essential. Ms M’s case clearly demonstrates the essential requirement of communication and transfer of information between medical practitioners as the crux of optimum patient management.

References

1. Mazza v Webb [2011] QSC 163
2. Sidaway v Board of Governors of Bethlehem Royal Hospital Board [1985] UKHL; [1985] per Lord Diplock at 893, cited with approval in Rogers v Whitaker [1992] HCA 58; (1992) 175 CLR 479 at 483.
3. Saunders BP, Trewby PN. Open access endoscopy: is the lost outpatient clinic of value? Postgrad Med J 1993;69:787-90.
4. Sheperd HA, Bowman D, Hancock B, et al. Postal consent for upper gastrointestinal endoscopy. Gut 2000;46:37-9.