Managing Urgent and Life Threatening Test Results

Case 1

A patient’s sexual partner was successful in his medical negligence claim against two GPs and a medical practice for failing to inform the patient in a timely manner that she had tested positive for HIV.¹

One of the GPs had been phoned by the pathology laboratory and informed that the patient’s HIV test was equivocal. The laboratory urgently faxed the results to the practice and recommended that the patient undergo retesting for HIV. The GP asked the practice’s administrative staff to send a recall letter to the patient asking her to attend the practice as soon as possible.

Five weeks later, the staff informed the GP that there had been no response to the letter. The GP asked the staff to phone the patient and also send her another letter. The next day, the staff informed the GP that the telephone number listed in the patient’s medical record was incorrect.

Two months after the initial phone call to the GP from the pathology provider, the patient attended the practice. The local sexual health clinic had made contact with the patient’s father and asked him to tell his daughter to attend the practice. Retesting confirmed that the patient was HIV positive but, by this time, she had engaged in unprotected sexual intercourse with her partner, who subsequently also tested positive for HIV.

Case 2

A recent Coronial Inquest into the death of Ms Lambert, a 69-year-old woman, reported the cause of death as a left pontine haemorrhage, in circumstances where there had been a delay in informing her of abnormal findings on a CT brain.²

Two weeks before Ms Lambert’s death, she had complained of slurred speech to her GP. The GP ordered a CT brain and a follow-up appointment was made for the patient to see the GP two weeks later.

Nine days after the GP appointment, the patient underwent the CT brain which suggested the possibility of a bleed or hypercellular tumour. The patient had left the radiology clinic by the time the scans had been reported and so the radiologist phoned the patient’s GP to inform him of the results.

The following day, the GP’s receptionist tried to contact the patient by phone. Fourteen calls were made to her home phone that day, none of which were successful. Four days later, the patient did not attend her scheduled appointment with the GP, and a further call was made to her home. Two further calls were made the next day, none of which were successful. The patient was found dead at home by her daughter later that day.

At the Inquest, the Radiologist gave evidence that she had recommended to the GP that the patient be promptly referred to a Neurologist and the GP had agreed to contact the patient. The Coroner was critical of the GP for not doing more than he did. The GP gave evidence at the Inquest that the patient needed to be contacted within two to three days. The Coroner found that the GP “appreciated the urgency and did not take sufficient steps to ensure that Ms Lambert be contacted”.

Recall and follow up of patients

The RACGP Standards for General Practices (the Standards) state that the following factors are important in determining if something is clinically significant and therefore requires follow up:

• the probability that the patient (or other person) will be harmed if adequate follow up does not occur
• the likely seriousness of the harm
• the burden of taking steps to avoid the risk of harm.³

What if you cannot contact the patient directly to inform them of urgent
and life threatening test results?

In some cases, it may be appropriate to do a home visit if the patient cannot be contacted by phone.

If the patient cannot be contacted directly in a timely manner, consider contacting the:

• patient’s “in case of emergency” contact or family member
• police and/or ambulance service.

If you need to contact a family member or the police, there is no need to provide clinical details. Simply ask them to either provide you with the patient’s contact details or to contact the patient on your behalf to ask them to contact you urgently.

Follow up of urgent and life threatening results out of hours

The Standards state that practices need to have arrangements in place to allow seriously abnormal and life threatening results identified outside normal practice opening hours to be conveyed to a medical practitioner in a timely manner, so the medical practitioner can make an informed and appropriate medical decision that is acted on promptly.³

For example, if a general practice uses a deputising service, the practice should have a defined and reliable system for the deputising practitioner to access patient health information or to contact the general practice. Pathology and radiology providers need to ensure they have up to date contact details for their referring practitioners and patients, so that in circumstances where a result is urgent and life threatening, direct contact can be made with the referring practitioner or, in exceptional circumstances, the patient directly.

Summary points

• Failures in the follow up of urgent results, e.g. raised troponin or grossly elevated INR, have been the subject of criticism in Coronial Inquests where patients have suffered harm through a lack of robust systems for communicating urgent information.
• Ensure you keep the patient’s and referring doctor’s (if applicable) contact details up to date.
• If a patient cannot be contacted to inform them of urgent and life threatening results, you should contact the patient’s “in case of emergency” contact or family member, the police and/or ambulance service.
• Seek advice from our Medico-legal Advisory Service if uncertain about how to proceed in a particular case.

Dr Sara Bird
Manager, Medico-legal and Advisory Services
MDA National

References
1. CS v Anna Biedrzycka [2011] NSWSC 1213. A detailed discussed of this case is provided in the article ‘Why Accurate and Current Medical Records Matter’ published in Defence Update Winter 2012. Available at: defenceupdate.mdanational.com.au/medical-records-matter/.
2. Inquest into the death of Judith Lambert, Coroner’s Court of SA, 13 June 2013.
3. RACGP. Standards for General Practices, 4th ed. See Criterion 1.5.3 System for follow up of tests and results, pp 40-44, and Criterion 1.1.4 Care outside normal opening hours, pp 17-20.