Misdiagnosis in discharge summary did not change patient’s outcome

Accurate diagnosis and accurate communication of the diagnosis are essential. Even a small error in a discharge summary can alter the treatment trajectory and delay appropriate care. Once a correct diagnosis is established, where multiple treatment options are available it is ultimately the patient’s decision as to which one to pursue. Doctors’ duty of care includes referring patients or advising them to seek specialist investigation or consultation, and to give them information they need to make an informed decision about treatment.

While a delay in seeking specialist advice will not necessarily mean a doctor is liable for any harm caused, it is good practice to discuss treatment options with the patient early, rather than waiting until one course of treatment proves unsuccessful.

C attended a regional hospital emergency department (ED) with a left shoulder injury. They were referred for an x-ray, which reported a left AC joint dislocation. Although the x-ray report identified a dislocation, the ED doctor incorrectly documented ‘subluxation’ on the discharge summary, effectively a misdiagnosis. This error minimised the seriousness of the injury and was carried through into the GP’s notes, influencing the decision to pursue conservative management.

The hospital did not have an orthopaedic department and C was discharged with advice to keep the arm in a sling and see their GP in two weeks.

The discharge summary did not suggest there were other management options, nor did it suggest that C seek orthopaedic review.

The GP’s notes recorded the injury as a joint subluxation. They also accessed the diagnostic report which referred to a dislocation. The GP preferred conservative management based on the reports and C’s presentation.

Around 8 weeks after the injury, when it did not resolve, the GP referred C for orthopaedic review. Further months passed before C was able to see a specialist and then have reconstructive surgery, due in part to public surgery waiting lists.

The surgery achieved a good anatomical result, but C continued to suffer pain and mobility restrictions and was unable to return to their pre-injury earnings as a plasterer.

C claimed they had suffered harm due to the hospital doctors’ negligence in:

• misreporting the injury and
• failing to advise C to seek orthopaedic review for advice on whether conservative or surgical treatment was most appropriate.

The discharge summary

There was no question the ED doctor had misreported C’s injury on the discharge summary. The correct diagnosis was a grade 3 AC joint dislocation. 

There was also no doubt that the ED doctor omitted to write in the discharge summary of the need for C to seek immediate orthopaedic review to determine appropriate treatment. The court accepted C’s evidence that he was not advised by the hospital doctors to seek orthopaedic review. He was however advised to see his GP, which he did. 

Did these errors make a difference to C's treatment? 

The court then needed to consider whether these errors made any difference to C’s treatment.

C consulted his GP as advised.  The GP recommended conservative treatment based on their own clinical judgement and was not misled by the reference to subluxation in the discharge summary.

The expert evidence and literature supported that both conservative and surgical treatments were widely accepted as competent professional practice for AC joint dislocations such as C’s.

The court emphasised that the central problem was not which treatment was ultimately chosen — both were valid. Rather, the misdiagnosis and lack of referral advice meant the patient was not fully informed about their treatment options.

In this case, C failed to prove that surgery was the preferred treatment. 

The court also considered whether earlier surgery would have resulted in a better outcome, finding that it would not have, and that it is widely accepted that both conservative and surgical treatments are competent professional practice for AC joint dislocations. 

Despite the clear misdiagnosis and communication errors, the court found C could not establish that these had caused them harm.

The court concluded C’s claim failed for several reasons:

1. The error on the discharge summary made no difference to the GP’s treatment. The GP brought their own clinical judgement to management of the injury and treated C accordingly.
2. C failed to establish they could have had earlier surgery, even if they had been advised to seek early review.
3. C could not show their loss of function was due to the delay in seeking orthopaedic review and surgery. There were multiple complicating factors that may also have contributed to the ongoing disability. These included C’s apparent failure to comply with the conservative treatment program of immobilisation and physiotherapy after the injury, as well as a later injury in a motor vehicle accident.

C’s claim for damages failed.

Ensure diagnoses recorded in discharge summaries are correct. Always check the records carefully to ensure they are accurate and up-to-date.  

Your duty to exercise reasonable care and skill includes referring patients for specialist investigation, or advising them to consult an appropriately qualified specialist who can advise them of treatment options. 

Breakdowns in handover or communication between clinical care teams can lead to diagnostic errors. When providing or accepting handover of care, make sure that the process provides accurate information sufficient to ensure ongoing care for the patient. 

Where various treatment options are considered acceptable practice, explain the options and your recommendations. Ultimately the decision will be the patient’s to make, based on their own situation including their needs, lifestyle, responsibilities and resources. 

Avant eLearning course – Medical records: part one - documentation

Avant factsheet – Missed or delayed diagnosis

Avant claims insights – Diagnostic error in claims