McCabe v Moore & Ors

A general practitioner must investigate symptoms in their clinical context. In a patient with an artificial heart valve, day and night sweats, unexplained weakness, lethargy and feeling unwell may constitute red flags for infective endocarditis. Where such information is volunteered, or reasonably should be elicited, the doctor must clarify its extent and significance. A doctor may adopt a wait-and-see approach to an isolated, apparently resolving leg complaint where no further symptoms are reported. However, unexplained sweats inconsistent with continuing menopausal symptoms required further questioning and, on the facts found, immediate hospital referral.

The claimant suffered a stroke caused by undiagnosed infective endocarditis following replacement of her aortic valve. She alleged that three general practitioners negligently failed to identify relevant symptoms, investigate her condition or refer her to hospital. The court considered what symptoms were present at each consultation, what the claimant told each doctor, whether further questions were required, and whether earlier investigation and treatment would have prevented the stroke.

The claim was brought against Dr Moore, Dr Fisher and Dr Hall. Liability and causation were tried separately from agreed damages.

1. The court applied the ordinary competent practitioner standard stated in Bolam v Friern Hospital Management Committee (1957) 1 WLR 582 and Sidaway v Governors of Bethlem Royal Hospital (1985) AC 871.

2. No breach was established against Dr Moore. The only complaint made on 30 March 2009 was leg pain related to running. The pain had substantially resolved, and waiting, observing and reviewing were appropriate. Further questioning was not mandatory on those facts.

3. No breach was established against Dr Fisher. His consultations concerned apparent renal colic, and the claimant did not report sweats, leg symptoms or other features requiring investigation for endocarditis.

4. The claim succeeded against Dr Hall. On 14 April 2009 the claimant reported pain in both legs, day and night sweats, and that her menopause had ended many years earlier. In a patient with an artificial valve, this combination raised a red flag. Dr Hall was required to clarify the symptoms, their duration and severity, and the claimant’s general condition. It was not permissible to assume that the symptoms represented continuing menopause.

5. The further questions would have revealed persistent night sweats, weakness, lethargy, reduced mobility and constitutional illness. The agreed expert evidence established that infective endocarditis should then have been considered, basic blood tests performed and the claimant referred or admitted to hospital immediately, no later than the following day.

6. Earlier admission would probably have led to blood cultures, echocardiography and appropriate antibiotics before 20 April 2009. On the expert evidence, that treatment would have prevented the stroke. Judgment was therefore entered for the claimant against Dr Hall; the claims against Dr Moore and Dr Fisher were dismissed.

not stated in the judgment.