Tucker v Griffiths

A general practitioner must refer a patient with a prosthetic heart valve where there are reasonable grounds to suspect infective endocarditis. Mere possibility is insufficient, while requiring the condition to be probable sets the threshold too high. The assessment is one of clinical judgment, applying the standards of the relevant period and without hindsight. Non-specific inflammatory markers may require further investigation but do not, without more, mandate immediate hospital admission. A further routine appointment may be reasonable where the history and presentation do not establish reasonable suspicion of infective endocarditis.

The claimant, a serving police officer with a prosthetic aortic valve, developed infective endocarditis and later suffered a stroke. He alleged that the defendant general practitioner negligently failed, on 29 November 2010, to suspect infective endocarditis and to refer him urgently to hospital after reviewing raised inflammatory markers. The parties agreed that earlier diagnosis and treatment would have prevented the stroke and agreed the value of the claim if liability were established. The central issue was whether a reasonably competent general practitioner should have made an urgent hospital referral.

1. The claim was dismissed. The relevant standard was that of a reasonably competent general practitioner applying the standards prevailing in November 2010.
2. The trigger for mandatory referral was a reasonable suspicion of infective endocarditis. The court rejected both the submission that any suspicion was sufficient and the defendant’s position that referral was required only where infective endocarditis was probable. The seriousness of the disease justified a high index of suspicion and a low threshold for investigation, but did not remove the need for clinical judgment.
3. The assessment had to be made without hindsight. On 29 November, the defendant knew of the earlier fever and rigors, the prosthetic valve, the intervening tachycardia, continuing malaise and raised inflammatory markers. However, there was no persistent or recurrent fever, obvious murmur, anorexia, back pain, night sweats, significant flu-like illness or abdominal pain. The inflammatory markers were non-specific and had several possible causes.
4. The results plainly required further investigation. The defendant’s decision to arrange another appointment was a reasonable response open to a competent body of general practitioners. Immediate admission was not mandated. Review by another GP in the practice was also acceptable, since that GP had access to the relevant records and investigations.
5. The defendant had infective endocarditis in mind as a possible, although unlikely, diagnosis. Her failure to listen specifically for a murmur did not establish that her evidence was unreliable, particularly as no murmur was recorded when the claimant was later examined by another GP.