Two general practitioners of a medical centre overlooked the abnormal urine results of a 4-year-old girl, thus, failed to diagnosis diabetes.
The Health and Disability Commissioner in its report found the two GPs breached the Code of Health and Disability Services Consumers’ Rights (the Code) in their care of this child.
The young girl was seen by the two doctors over two separate appointments in November 2020. In both consecutive consultations, the girl’s abnormal urine results, obtained by triage nurses, were overlooked. The child’s parents were also not informed about the concerning results. These omissions led to a delay in the girl being diagnosed with type 1 diabetes.
The girl presented to another doctor a few days later and was diagnosed with type 1 diabetes and referred to hospital for treatment. The delayed diagnosis caused significant stress for the girl’s family.
The Deputy Commissioner, Dr Vanessa Caldwell found that by failing to appropriately review and act on the abnormal urine results both doctors breached Right 4(1) of the Code, which gives consumers the right to services of an appropriate standard.
“The accepted practice is for a GP to review triage observations as part of patient assessment,” said Dr Caldwell. “I am critical that both doctors overlooked the urine results during their appointments with the girl. In my view, the doctors’ omissions led to a delay in the girl being diagnosed with type 1 diabetes.”
In her findings, Dr Caldwell noted that while the medical centre is also responsible for providing services in accordance with the Code, the deficiencies in the doctors’ care were individual clinical failures. However, she did make an adverse comment about the company’s triage guidelines. “I am concerned that the triage guidelines in place at the time were not sufficiently clear to guide nursing staff to appropriately respond to a child at risk,” Dr Caldwell said.
“Nonetheless, guidelines should not replace clinical judgement and critical thinking. Regardless of the adequacy of the guidelines in place at the time, I am most concerned that two doctors at the centre failed to look at the urine test results, despite the results being available for their perusal.”
Dr Caldwell recommended that both doctors provide a written apology to the family for the breaches in care. She also made a number of recommendations to the medical centre, including that they provide HDC updates regarding changes to triage resources and the effectiveness of those changes and that they use the HDC report to share lessons and educate staff.
“I acknowledge that the medical centre, and the doctors have altered their practice (including introducing a Paediatric Early Warning Score) to prevent any further omissions, and have created new policies and tools to better identify risk to its younger patients,” Dr Caldwell said.
– from NewsViews
