This case is based on a real scenario, with some facts altered to preserve confidentiality.
Mrs F, a 68-year-old woman with a past medical history of hypertension and diabetes, was diagnosed with adenocarcinoma of the lung. This was considered to be non-operable, and she was offered palliative chemotherapy. Mrs F opted to undergo this on a private basis under the care of Dr B, a consultant oncologist.
Her treatment was with carboplatin and pemetrexed, and she underwent two cycles with no concerns.
Prior to the third cycle of chemotherapy, an increase in creatinine was noted, having risen from 70umol/L to 101umol/L. It was considered, however, that it was still appropriate to proceed with the third cycle, and this was completed without complication. A CT scan showed a good response to treatment.
Blood results prior to the fourth cycle, however, demonstrated a further rise in creatinine to 173umol/L. This result was not seen by the Consultant Oncologist when prescribing the chemotherapy – instead, Dr B reviewed the results from the previous cycle in error. Mrs F therefore received the fourth cycle, and the plan following this was for maintenance pemetrexed.
Blood test results several days prior to the first planned dose of maintenance pemetrexed showed a significant fall in haemoglobin from 110g/L to 59g/L, along with a rise in potassium from 4.5mmol/L to 6.3mmol/L and a creatinine of 589umol/L. At the time of the blood test, Mrs F reported feeling breathless and fatigued.
The abnormal results were telephoned to the nursing staff by the laboratory, and the nursing staff left a message for Dr B relaying the low haemoglobin levels, but not the other results.
Dr B called the nursing staff in return to ask them to make arrangements to admit Mrs F urgently for a blood transfusion. Dr B did not enquire about any of the other blood test results at the time of the phone call, and the nurses did not convey any additional information about the remainder of the tests.
Mrs F was subsequently admitted, and the Resident Medical Officer (RMO) prescribed a two-unit blood transfusion, having been asked to do so by the nursing staff. No diuretics were prescribed and no treatment was given for the raised potassium. Dr B did not attend the hospital to review Mrs F, considering this to be a straightforward admission for a blood transfusion.
Partway through the transfusion Mrs F became acutely breathless and unwell. The RMO was asked to review the patient and contacted Dr B for further advice. At this point, Dr B was made aware of the other abnormal blood results, and arranged for transfer of Mrs F to the NHS setting for further management.
It was considered that Mrs F had developed fluid overload and acute pulmonary oedema. She required a period of time in intensive care. Following these events, her renal function remained poor, with a creatinine consistently around 500 umol/L, and it was considered that no further chemotherapy could be offered.
Mrs F brought a claim against Dr B alleging the following:
Expert evidence was obtained from a consultant oncologist and a consultant nephrologist. The experts concluded that no dose reduction at the time of the third cycle of chemotherapy was necessary, but the fourth cycle should not have proceeded. It was also concluded that Dr B should have looked at the full set of blood results obtained around the time of the transfusion, and Mrs F’s potassium level and renal function should have been addressed prior to starting the transfusion. Had this been the case, the episode of pulmonary oedema and the requirement for admission to intensive care would have been avoided.
It was considered, on the balance of probabilities, that the cause of Mrs F’s chronic renal failure was multifactorial, but that the administration of the fourth cycle of chemotherapy contributed more than minimally. In the absence of chronic kidney damage, it was agreed that further palliative chemotherapy was likely to have been considered, although it was noted that, due to co-morbidities and the advanced nature of the cancer, Mrs F’s renal function and performance status may have deteriorated in any event, such that further treatment would have been inappropriate.
The claim was settled for over £60,000, including damages and legal costs.
Ensure dates are checked when reviewing test results to ensure that information used to base clinical management or for prescribing decisions on is the most up to date. Had Dr B reviewed the most recent blood results, the fourth cycle of chemotherapy would not have proceeded.
Consider all relevant information when advising on the management of a patient, especially when doing so remotely. While it is acceptable to rely on information communicated by a colleague, Dr B retained overall responsibility for the patient and needed to ensure they were satisfied that they had relevant and sufficient information on which to base their clinical decision making. Had Dr B enquired about, or accessed, the rest of the blood test results at the time of advising a blood transfusion, Mrs F’s raised potassium and renal failure would have been identified earlier, and it is likely the episode of pulmonary oedema and the requirement for intensive care would have been avoided.
When admitting a patient to a private hospital on an urgent basis, consider whether it would be appropriate to review the patient in person on arrival, or ask that a colleague (such as the RMO) review them. Had Dr B attended the hospital to review Mrs F prior to the transfusion, or requested that the RMO review prior to prescribing blood, it is likely that the remainder of the abnormal blood results would have been identified at that point.