HDC case - delay in diagnosis of diabetes

The Health and Disability Commissioner (HDC) has released a decision on a case involving a woman in her seventies who had a history of diabetes, hypothyroidism, COPD, morbid obesity, and lung cancer.

The patient, who sadly died before the decision was released, made three complaints about doctors in her medical centre. Two were not substantiated, but the third brought criticism from the HDC.

Type 2 diabetes

In February 2018 Mrs A had a routine HBA1C test with a reading of 50 mmol/mol. Records show that she had no symptoms and the implications of this were discussed along with a plan of action by Dr C. The tests were repeated in May and July 2018 with results of 49 mmol/mol. Dr C left the clinic six months later.

15 months later in November 2019, Mrs A had routine bloods as part of a pre-anaesthetic check for a hernia operation. Her blood showed an HBA1C of 89 but the initial results were not sent to the medical practice. A second set (on 28 November 2019) which showed a similar result, was sent to the practice. This second set of results was presumably discussed with her by her anaesthetic consultant.

On 4 December 2019, Mrs A had a consultation with Dr B (another doctor in the medical centre) who noted that Mrs A was “upset” but without explaining why. She was started on metformin and apparently her readings improved on the medication.

The Commissioner was critical that contrary to Diabetes New Zealand guidelines, Mrs A did not have her HBA1C checked annually to determine whether they had progressed to type 2 diabetes, and was not put on a recall to check this.

Lung cancer

Subsequently, the patient presented on five occasions to Dr B between August and December 2020 with exacerbations of bronchitis secondary to her COPD, along with a progressively swollen leg. On each occasion she was treated appropriately and in October 2020 she was admitted. During the admission, she was found to have a normal chest X-ray but aspergilla was grown in her sputum. She also had a D-dimer test done which was negative.

On two further occasions she was seen with respiratory symptoms and an increasingly swollen leg. It is obvious that her doctor had been reassured by the negative chest X-ray and the negative D-dimer. Notwithstanding Dr B repeated D-dimer in mid-December, and this time it was positive but an ultrasound was negative

On 30 December 2020, the patient went to an ED with severe shortness of breath and cough. On her admission, a CT scan showed a significant and inoperable carcinoma of the lung. The hospital reviewed the chest X-ray done in October and reported that the malignancy was not visible.

The primary care doctors were considered to have acted appropriately, particularly in the light of the negative chest X-ray and D-dimer tests. There was, however, criticism that although Dr B stated that at every consultation he had measured her pulse, blood pressure, temperature and respiratory rate, these measurements had not been recorded.

Incorrect ethnicity coding

The patient learnt that she had been classified as a “New Zealand Maori” when she enrolled to the practice in 2009, when she was in fact European. She made the interesting suggestion that she could have been experiencing racism in the care provided to her.

The practice stated that this was not the case and apologised for the coding error. The Commissioner accepted that this was a coding error but suggested that the practice should be more careful.

How did this complaint develop?

It appears that the seed of doubt was sown when Mrs A learned about the rapid development of her type 2 diabetes diagnosis. This was followed by repeated episodes of acute bronchitis, and her deteriorating health was plainly a real worry for her. The tragic discovery of an occult terminal illness was the final straw.

The Commissioner has again highlighted their belief that case notes need to document both positive and negative findings to a degree that resembles a legal document. This is an area that needs more debate.

Moreover, the Commissioner has identified a guideline written by Diabetes New Zealand on the management of pre-diabetic HBA1C levels and treated it as a protocol. They have then gone further and stated that she should have been on a recall list.

In this case, a woman in her 70’s with readings that, albeit only slightly, improved with lifestyle changes would not normally be regarded as being at risk of the significant change that did occur. We all need to debate whether low risk patients do need to be on recall lists, or whether it is reasonable to routinely follow them up at their next visit. Something like “Mrs A we should check your HBA1C annually and I will write it in your notes so we can both remember to do it”.

Should a rare case be such that management for all such patients is treated with a rigid protocol?