Anaemia can be more than a diagnosis

Introduction 

The Health and Disability Commission (HDC) has recently reported on the case of a woman (Ms A) who was in her 20’s when she was treated for persisting iron deficiency anaemia over a period of 22 months but subsequently died from complications of a carcinoma of the bowel. 

The case was complicated by several factors, including confusion as to who the “owner doctor” was, Ms A’s complicated medical history and a delay in investigating the root cause of the anaemia. 

This was further complicated by the patient not having blood tests done when asked and was possibly not adherent with taking oral iron. Her sister however made the point that Ms A was tired and was continually sent home with the same medication, so this was not surprising. 

The case 

Ms A was first diagnosed with iron deficiency anaemia in 2016 when she presented for a preconception medical check, but it was likely that the anaemia had been present for some time before that. Her initial blood test in 2016 showed a typical iron deficiency with a haemoglobin of 87g/L which subsequently varied from 77 to a maximum of 101 after an iron infusion. In addition to the prescribed oral iron, she was given intramuscular iron injections along with the infusion some months before her death which was carried out as an outpatient procedure at the public hospital.  

Although Ms A was diagnosed and treated for her anaemia, the actual cause was not further investigated and was presumably thought to be due to menorrhagia and/or dietary imbalance. There was no obvious investigations to confirm this. 

Other medical history  

In 2017 Ms A was diagnosed with a benign breast lump which was subsequently excised and at her pre-operative assessment she was noted to be anaemic, and the anaesthetist requested that she be given iron to correct this. 

In 2018 Ms A was seen a total of 22 times for a variety of symptoms including for her anaemia.  

Five months before her final diagnosis she presented with back pain and was examined. She also had a cervical smear; and the cause of the pain was put down to a musculoskeletal problem.  Over the following two months she was seen acutely at the hospital emergency department (ED) on two occasions with abdominal pain, rectal bleeding and haemorrhoids and was diagnosed with gastroenteritis. Surprisingly, there was no reference to a rectal examination. 

Two months before her final diagnosis she also presented to her doctor twice with abdominal and pelvic pain which was worse on movement. She was examined and a semi urgent ultrasound was ordered as the pain did not appear to be severe. Before this could be carried out, Ms A went overseas where she became acutely unwell, and a CT showed an inoperable carcinoma of the bowel. A colonoscopy also showed multiple polyps as well as a malignant mass. 

Ms A returned home and died a few weeks later. 

Management by Ms A’s general practice 

Ms A was seen by a variety of doctors on numerous occasions, but she saw two doctors at her general practice for her anaemia, Drs C and D. Dr C was an owner of the practice and all patients at that time were registered to her. She said that Dr D was responsible for Ms A’s care and her management of the  anaemia was “minimal." On the other hand, Dr D stated that she was a locum and was always under the impression that Dr C was her regular doctor. 

The confusion of who had overall responsibility was further confused by a lack of communication between the two doctors. 

The HDC view 

The Commissioner was critical of: 

• The lack of clear responsibility for the care of Ms A and the lack of communication. 
• The fact that despite quite severe and chronic anaemia there had not been further investigations undertaken. 

The Commissioner noted that the presentation of such a malignancy was very rare in a patient so young and that the abdominal symptoms presented late in the illness.  

Learnings

It is tempting to look at chronic conditions like anaemia as a diagnosis, but the reality is that the actual cause needs to be identified. The HDC identified that there are agreed management pathways for anaemia, and they need to be adhered to. 

Continuity is a key factor in the long-term care of patients. International research shows it's a key factor in good patient outcomes. Where patient continuity is not possible or does not occur, there needs to be clear practice protocols in place to ensure there is appropriate follow-up of the patient with long term or ongoing medical issues. Clinical governance is critical to ensure this happens. The medical practice, as an entity, must focus on ensuring that there are clear lines of communication between different players in a medical centre. 

In this case, an earlier diagnosis may not have made a difference to the outcome, however, there needs to be a focus on the follow up of abnormal results.