GP's failure to recall patient leads to Ahpra complaint

A GP’s systems for patient recall were inadequate and led to a complaint with Ahpra, after he failed to recall a patient when pathology results indicated she required further treatment.

Practice systems for patient follow-up and recall can be critical to patient outcomes, particularly where pathology results are involved. In this case, a GP relied on an informal process of checking and following up on pathology results, and failed to pick up that the patient’s results indicated further treatment was required.

Treatment

The GP had consulted with the patient in relation to a lesion that had been identified through biopsy as a fast-growing basal cell carcinoma (BCC) requiring excision. After discussing the need for this procedure with the patient, and obtaining informed consent, the GP performed the excision under local anaesthetic and sent the excised lesion for pathology testing.

In the days that followed, the patient returned to see the GP several times for wound care. The day after the excision was performed, the histopathology report of the lesion was sent to the GP. This report identified the lesion as an ulcerated moderately differentiated basaloid squamous cell carcinoma, measuring at least 25mm x 20mm. While the margins were noted to be clear at 3 o’clock, 6 o’clock, 9 o’clock and 12 o’clock, it was also noted that the deep margin was focally involved.

It was this finding of deep margin focal involvement that ought to have prompted the GP to discuss the result with the patient and either perform a deeper excision himself or refer her to a specialist.

A number of months later, the patient went to a surgeon for removal of lumps that had appeared under her arm. These were subsequently identified as BCC and it was alleged that the GP’s failure to obtain clear deep margins had led to the spread of the BCC to the patient’s lymph nodes. The patient subsequently lodged a complaint with Ahpra, alleging that the GP’s failure to perform a deeper excision or refer the patient to a specialist had led to a deterioration in her condition.

Failure of systems

Unfortunately, in this instance, the system that the GP had been relying on to alert him to results of this nature that required further action, was not effective.

The GP advised that, in the usual course, he would be notified of results such as these by checking his email inbox, which he would do numerous times each day. When he would receive a result like this in his inbox, his practice had been to note the result and ensure that he discussed it with the patient when they next attended at the practice, for example, for wound care.

Considering this matter with the benefit of hindsight, the practitioner was not able to identify whether he had not picked up the patient’s results, or whether he was alerted to them but then failed to take further steps to action them. Regardless, the result was the same; his system had failed and the patient was not recalled and advised that further excision of the lesion was necessary.

Responding to the complaint

Avant’s medico-legal team helped the GP submit a response to Ahpra that outlined his treatment of the patient, as well as providing his sincere apology to the patient that the systems he had put in place for recall had not worked as they should have in her case.

The GP also set out in his response the steps that he had taken to change his practice to ensure that such an error would not occur again. These included:

• Using the practice software to generate a reminder to discuss pathology results with patients. This would mean that whenever he or another practitioner at the practice opened the patient’s file, it would have a reminder to discuss the pathology results with the patient.
• Instituting a practice of printing out pathology results in hard copy to give to the patient when they next attended at the practice, as a further prompt to remind him to discuss the results.
• Creating a routine practice to always discuss pathology results for skin excisions when the patient attends the practice for wound review or removal of their sutures.

The GP also engaged with Avant’s Risk Advisory Service and, in order to improve his practice, proactively completed a course of education relating to patient follow-up and recall provided by Avant

The Medical Board considered the explanation provided by the GP and, taking into account his reflection, his sincere apology and the actions he had taken to improve his practice, determined that no further regulatory action was required.

Key lessons

• Deficiencies in practice systems with respect to patient recall and follow-up can have a real impact on patient outcomes.
• The best systems for patient recall and follow-up make use of practice software systems and do not depend on individual practitioners remembering to take certain steps.
• The use of ‘reminder’ or similar functions in practice software can be invaluable to ensure important results are not missed.
• Our experience is that, when responding to a matter of this kind, candour and genuine remorse and reflection on the part of the practitioner will be taken into account by the regulator.

This article was originally published in Connect magazine issue 21.