HDC case - lump in neck

By Dr Peter Moodie, College Clinical Advisor

29 September 2023

Category: Clinical


The case

On the Saturday 24 February 2018, Mrs A was seen at an emergency department after suffering an injury to her shoulder. She had an X-ray and a CT scan, neither of which showed any fractures. She was discharged with a diagnosis of a soft tissue injury only, and told to see her own Dr B on Monday 26 February.

A discharge summary was sent to Dr B on 24 February, and was subsequently amended and resent later that same day. On Monday 26 February the discharge summary was again amended and sent at 11.50 am.

Dr B agreed that he had seen and read the first two discharge summaries but he said that he thought the third was just a repeat and so he filed it without checking it. Mind this: it is likely that he actioned the first two and possibly the third, all on the Monday.

Amendments to the discharge summary

The third amendment had two important details in it:

The first new detail was that the CT scan had been now formally reported and there was a coincidental but suspicious 17 mm lesion in Mrs B’s neck. It was advised that an ENT opinion should be sought. The second detail was a note from an un-named clinician which read:

“I have discussed this CT result with Dr B who will organise ENT follow up for Mrs A. I couldn’t get hold of Mrs A on her phone”.

Dr B was criticised and censured for not reading the third discharge summary carefully.

Dr Peter Moodie

What followed

Mrs A was seen in the morning of 26 February as arranged, and the case notes make no reference to the CT scan or the suspicious lesion. She was treated for her hip pain and an ACC certificate issued.

In 2020 Mrs A attended an accident and emergency clinic, again with a sore hip. The CT scan report was seen and she was told about the neck lesion and referred to ENT. The lesion was found to be a metastatic squamous cell carcinoma.

Inevitably Dr B was criticised and censured for not reading the third discharge summary carefully and for not acting on the phone call from the hospital clinician. Dr B was adamant that he never received the clinician’s phone call, and explained that he never accepts calls on the weekends, so the call had to have come in before 11.50 am on 26September. He further explained that he could show that he was consulting from 9.00am that morning. What is more, he saw Mrs A in that same period and it beggared belief that he would have overlooked the advice.

What are the possible scenarios?

  • Dr B was recalling details which had occurred some 2 ½ years previously and he may have been mistaken.
  • The hospital clinician wrote what he intended to do rather than what he did.
  • Although very unlikely, the clinician might have rung the wrong doctor.

One further point, which was not made by Commissioner, is that when discharge or other documents are transmitted and then amended, there should be a very clear warning that there is new information in the documents. If these had been amended instructions to an airline pilot and it resulted in a “near miss” or even a crash, I suspect that there would quickly be a nationwide management policy on how amended documents should be transmitted.

Message from the College's Medical Director Luke Bradford

In response to the issue of amended discharge summaries and the cc’ing of results by secondary care clinicians to GPs without a formal transfer of care, the College has organised a conversation with MCNZ, HDC, Manatū Hauora and Te Whatu Ora. This conversation will address the clinical risk and administrative burden of this unsolicited non-communicated workload and will drive for a change in current practices.