The importance of run-off cover following cessation of practice in NZ

The following HDC report regards the care of a woman between 2010 and 2018 and the delay in her diagnosis of Multiple Sclerosis (MS). Several parties were involved, including the Canterbury District Health Board, a Medical Centre, and a General Practitioner, Dr B. 

In 2010, the woman was referred by her GP to the ophthalmology service with sudden, unexplained vision loss. She was diagnosed with demyelinating optic neuritis, often associated with MS. A subsequent MRI confirmed this and revealed abnormal lesions in the white matter. She was therefore referred to the neurology service with the possibility of a diagnosis of MS and was prioritized as “semi urgent”. However, due to limited resources the referral was declined, and she did not receive an appointment with the neurological service. 

In 2015, the woman presented to her GP, Dr B, with peripheral neurological symptoms. He considered the possibility of a mini stroke or inflammation and ordered tests but did not initiate a management or follow up plan. 

In 2018, the woman presented to the medical practice with vomiting and collapsing at the medical centre. Dr B. thought this was related to a migraine or an inner ear disorder. 

A few days later, the woman called the practice complaining of diplopia and spoke with a nurse, but this consultation was not recorded.

In 2019, the woman presented with worsening vision in her right eye and peripheral tingling sensations. On this occasion she saw a different GP who noted the documentation from the MRI scan in 2011 suggesting demyelination. She was urgently referred to the neurology service and was diagnosed with MS. 

The Deputy Commissioner found the CDHB at fault, despite the extraordinary circumstances of the 2011 Christchurch Earthquake. It was deemed not reasonable to decline the referral without any further consultation or advice. The Medical Centre was found not to have breached the Code of Rights, but the Commissioner made an adverse comment about the lack of nurse documentation

Dr B (who saw the woman in 2015) was found in breach of the Code, as he should have referred her to a neurologist and developed a follow-up plan.

This is a case of missed opportunities and resource constraints. In addition, there are concerns around filing and alerting of correspondence within the general practice. From the outset, the woman should have had safety netting and recalls set in place to ensure she was referred to a neurologist. Hospitals, when faced with growing constraints, must also improve communication with patients and provide clear advice and safety-netting - simply declining a referral is not acceptable. If Dr B. had seen the previous issues noted in 2010, (perhaps done a quick file review before seeing her) it is likely the MS would have come to light sooner. 

This hearing took place after Dr B had retired, so one can only hope Dr B had run off cover from his indemnity provider to fund the necessary legal and collegial support required. Medicus offers run-off cover for retired doctors to ensure they are adequately protected should any historical issues, like this one, arise.

Read the full case here.

Dr Andrew Dunn

General Practitioner