Sample Report

Estate of Mr John Smith (deceased) -v- Drs A & B.

Final Report of Dr Thomas William Caudell, BM, MRCGP for the Court

Contents

Report

1.01    The Writer

I am Dr Thomas William Caudell. My specialist field is General Practice. I am a registered medical practitioner, member of the Royal College of General Practitioners, and am on the General Practice register. I am a Partner and GP Principal in a large NHS teaching practice. Full details of my qualifications and experience entitling me to give expert evidence are in appendix 4.

1.02    Summary of the case

This case concerns Mr Smith, who had a CT scan of his coronary arteries (arteries that supply the heart) in November 2013 which showed a minor abnormality in the left lung which was thought to be benign. He subsequently presented to his GPs with recurrent cough over the following year. He was then referred to a respiratory physician and was diagnosed with a left sided lung cancer in January 2015. He sadly passed away as a result of an intracerebral haemorrhage (bleed into the brain), secondary to brain metastases (cancer spread) in April 2015. It is alleged that earlier investigation and/or referral by the treating GPs may have improved the prognosis.

1.03    Those involved in the case

Mr John Smith (deceased), on behalf of whose estate the claim is brought

Dr A, GP & Defendant

Dr B, GP & Defendant

Dr C, GP

Dr D, GP

Ms E, Nurse Practitioner

1.04    Summary of my conclusions

This report will show that, in my opinion, the care that Mr Smith received was of an unacceptable standard.

1.05    Technical terms and explanations

I have indicated technical terms in italics and defined them where first used. They are listed in the glossary in appendix 1.

1.06    A note on terminology

Where I state that a standard of care or practice is of “an acceptable/unacceptable standard”, this should be taken to mean “an acceptable/unacceptable standard as would be judged by a responsible body of General Practitioner opinion”.

2.01    My written instructions in this matter are from Jones & Jones LLP. The Claimant’s solicitors have asked me to offer an opinion on alleged breach of duty on the part of the GPs involved.

2.02    I have been asked to answer the following specific questions:

1. What, if any precise aspects of our client’s medical treatment fell below the required standard?

2. Do you recommend that a further medical report be commissioned from a medical expert of different specialism?

3. Do you recommend that any particular tests or other investigations are pursued to enable you to provide a firm opinion?

3.01    The national guidance that was in force at the time of the events in question with respect to referral for suspected cancer was contained in: Referral guidelines for suspected cancer (quick reference guide) issued by the National Institute for Health and Clinical Excellence in June 2005.¹

3.02    Regarding lung cancer it says:

“Refer urgently [to a lung specialist] patients with:

3.03    It goes on to say:

“Refer urgently for chest X-ray (the report should be returned within 5 days) for patients with any of the following:

• haemoptysis [blood in the sputum]
• unexplained or persistent (longer than 3 weeks): chest and/or shoulder pain, dyspnoea, weight loss, chest signs, hoarseness, finger clubbing, cervical or supraclavicular lymphadenopathy [enlarged lymph nodes], or cough
• features suggestive of metastasis from a lung cancer (for example, secondaries in the brain, bone, liver, skin)
• underlying chronic respiratory problems with unexplained changes in existing symptoms.”

4.01    Mr Smith was a life-long smoker. 

4.02    Following a referral to the chest pain clinic for suspected ischaemic heart disease, Mr Smith underwent a CT scan of his coronary arteries in November 2013. The results of the scan were reassuring from a coronary point of view, but it did find a minor abnormality in Mr Smith’s left lung. The letter from the consultant cardiologist to the general practitioner dated 11/11/2013 says:

“…the patient was noted to have likely inflammatory changes with focal bronchiectasis in the apical segment of the left lower lobe. I have reviewed this with my radiology colleague, Dr X, who feels that it is a relatively confined area of inflammatory change and not something that requires further follow-up, unless the patient has any symptoms of concern such as productive cough or significant breathlessness.”

4.03    On 25/01/2014, Mr Smith consulted Dr C. The medical records entry reads:

“Problem: Chest infection (First)

History: URTI [upper respiratory tract infection] 1/52 [1 week] but left with purulent sputum & postnasal catarrh & fever

Examination: RR [respiratory rate] normal, coughing, chest basal coarse crackles

nasal congestion

Comment: discussed expectations”.

It appears that a prescription for amoxicillin (an antibiotic) was made out according to a subsequent records entry, but this is not apparent from the records entry of this date.

4.04    On 01/02/2014, Mr Smith consulted Dr B. The medical records entry reads:

“Problem: Chest infection (Review)

Medication: Doxycycline [an antibiotic] 100mg capsules One To Be Taken Twice A Day 14 capsule

Test request: Laboratory medicine - Unknown specimen

Test request: Cholesterol

Test request: Creatine Kinase (CK)

Test request: Liver Profile

History: feels worse with chest despite a week of Amoxil [amoxicillin]

Examination: apyrexial chest clear now

Comment: switch to doxy

History: also some myalgia on statin

Comment: check Ck and Chol ?scope for dec dose.”

4.05    On 19/02/2014, Mr Smith consulted Dr D. The medical records entry reads:

“Medication: Salbutamol (a bronchodilator medication]) 100micrograms/dose inhaler CFC free One Or Two Puffs To Be Inhaled two Times A Day When Required 1 x 200 dose

Comment: If goes on for 6-8 weeks tcb may need CXR

trail of inhaler to see if helps with cough

Problem: Cough (First) Severity: Mild

History: On-going cough clear sputum, smoker no weight loss

Examination: rr = 12 sats= 98%

hr 74

chest - clear nil focal”. (Her typos.)

4.06    On 21/03/2014, Mr Smith consulted Ms E. The medical records entry pertaining to the initial telephone consultation reads:

“Problem: Chesty cough (New) – hx from [redacted], works a anytown and unable to have his phone on him, recurring cough, non-productive, has been using his inhaler this am with little effect. worried may have a chest infection. no chest pains, will see pm.” (Her typos.)

4.07    The medical records entry pertaining to Ms E’s face-to-face consultation with Mr Smith on 21/03/2014 reads:

“Examination: O/E - normal respiration , although slightly reduced entry to right LL, talking in full sentances

O/E - trachea central O/E - chest expansion normal O/E - percussion note normal Blood oxygen saturation 96% O/E - pulse rate 88 beats/min O/E - rate of respiration 14/minute O/E - temperature normal

History: feeling unwell, productive thick brown phlegm , some pain to right side posterior chest wall, no crepitus, unable to reproduce pain on palpation.

Comment: treated for LRTI , has appt in 1 week as FU ? referral for CXR. to continue with inhaler as prescribed if helpful. Rv if SOS”. (Her typos.)

4.08    On 19/08/2014, Mr Smith consulted Ms E. The medical records entry reads:

“Medication: Amoxicillin 500mg capsules One To Be Taken Three Times a Day 21 capsule

Examination: chest examined - equal expansion , caorse breath sounds, states now nealry 6 weeks of coughing , productive at times - now occasional blood in sputum, harsh cough . uses benylin at night to help. continues to smoke. worried what last CXR showed - dtated march 2010 and reported as normal.

temp 36

Blood oxygen saturation 98% O/E - pulse rate 79 beats/min

Comment: try oral AB’s as hx of prolonged cough

RV if and Nopt improving

aware smoking will aggravate the cough

fluids +++”. (Her typos.)

4.09    On 24/09/2014, Mr Smith consulted Dr B. The medical records entry reads:

“History: ongoing cough, on doxy from wic [walk in centre], occ blood smoker

Comment: for cxr

Examination: apyrexial, chest clear,sats 98 pulse 85

Problem

Procedure: Seasonal influenza vaccination Manufacturer: abbott, Expiry Date: 30-Apr-2015, Batch Number: go2n, GMS: GMS, Injection site: Left arm

Problem: Bronchiectasis (chronic lung infection) (Review) Laterality: Left”.

4.10    A chest x-ray dated 25/09/2016 was unremarkable.

4.11    On 29/10/2014, Mr Smith consulted Dr A. The medical records entry reads:

“History: cough for several months ,dry cough with white mucus. now smoking about 5 /day. no breathless ness. breathes in fumes at refinery. had 2 lots of a/b no good.

Examination: sats 98%. pulse 98/min chest clear. dry cough plus plus.

Comment: to try a salbutamol plus volumatic

Medication: Salbutamol 100micrograms/dose inhaler CFC free 2 puffs qds 1x 200 dose

Volumatic (GlaxoSmithKline UK Ltd) ad 1 device

Problem: cough”.

4.12    On 10/11/2014, Mr Smith spoke to Dr B on the telephone. The medical records entry reads:

“Medication: Varenicline (a smoking cessation drug) 1mg tablets and Varenicline 500microgram tablets To Be Taken As Directed 25 tablet

Doxycycline 100 mg capsules One To Be Taken Twice A Day 14 capsule

Problem: Bronchiectasis (review) laterality: left

History: ongoing cough white sputum,occ blood. refer chest docs.

Comment: try antibiotics. coughing a ot on the phone. but not ill with it.” (Her typos.)

4.13    Dr B referred Mr Smith routinely to the chest clinic, where he was seen on 06/01/2015. A CT scan of his chest that was organised demonstrated a large left-sided lung cancer. It was planned that he would have radiotherapy and chemotherapy to treat this

4.14    Sadly, Mr Smith passed away in April 2015 as a result of an intracerebral haemorrhage, secondary to a brain metastasis from this lung cancer, before he could have his treatment.

5.01    The CT report from November 2013 made no mention of any signs of potential malignancy. It simply mentioned inflammatory change and possible bronchiectasis. It is inconceivable that, had either the consultant cardiologist or consultant radiologist been remotely concerned that the appearances were representative of a possible cancer, they would not either have arranged further investigation, referred Mr Smith to a respiratory physician, or asked his GP to refer him to a respiratory physician. It is my opinion that the GPs involved were entitled to rely upon this fact. It should also be noted that neither the cardiologist nor the radiologist have any particular special expertise with regards the presentation or management of either bronchiectasis or lung cancer.

5.02    Bronchiectasis is a chronic (long-term) condition that causes cough, breathlessness, and recurrent chest infection symptoms. This condition is not usually curable, and its symptoms are usually managed in primary care, unless severe and life-limiting, in which case a respiratory physician may be involved in the management.

5.03    Therefore, based upon the CT scan results of November 2013, and Mr Smith’s subsequent presentations, I am of the opinion that there was no specific duty on Mr Smith’s treating GPs to refer him to a respiratory physician for suspected cancer based purely on the CT findings and his repeated presentations with cough. This is because the information available to the treating GPs was that he had CT images consistent with bronchiectasis, not cancer, symptoms of recurrent cough would be consistent with this condition, and the condition is usually managed in primary care.

5.04    When Mr Smith presented to Dr C on 25/01/2014, he had only had a cough for a week. There was therefore no requirement for Dr C to refer him for suspected cancer according to NICE guidelines. Dr C’s practice on that date was of an acceptable standard.

5.05    Similar considerations apply to the consultation with Dr B on 01/02/2014, and her practice on that date was therefore also of an acceptable standard.

5.06    When Mr Smith consulted Dr D on 19/02/2014, the cough had been going on for approximately 32 days, well in excess of the three week time period beyond which NICE recommends referral for a chest x-ray. Despite this, Dr D did not make such a referral. Being a lifelong smoker, Mr Smith was at particularly high risk for lung cancer. It is therefore my opinion that no responsible body of general practitioner opinion would support Dr D's failure to refer for a chest x-ray on 19/02/2014.

5.07    On 21/03/2014 when Mr Smith consulted Ms E, it is not clear how long the cough had been going on for. It is therefore difficult to conclude whether or not a referral for a chest x-ray should have been made at this point in time.

5.08    On 19/08/2014, when Mr Smith consulted Ms E again, he was complaining of a history of cough for nearly 6 weeks, and was complaining of blood in his sputum (haemoptysis). Persistent cough for more than three weeks, and haemoptysis, are both independent red flags for lung cancer, and according to NICE each of these features individually would have indicated referral for chest x-ray. It is therefore my opinion that, especially bearing in mind Mr Smith’ smoking history, no responsible body of general practitioners would support Ms E’s failure to refer for a chest x-ray on 19/08/2014.

5.09    On 24/09/2014, Mr Smith consulted Dr B again complaining of a persistent cough and occasional haemoptysis. Dr B correctly referred him for a chest x-ray. This is consistent with NICE guidelines and it is my opinion that Dr B's practice was of an acceptable standard on that date.

5.10    The chest x-ray that was undertaken on 25/09/2014 was unremarkable. Therefore, whilst I have identified care that was of an unacceptable standard on 19/02/2014 and 19/08/2014, in terms of the failure to refer for chest x-ray, even if these breaches had not occurred, the chest x-ray would still have been normal, and therefore no causative effect can be implied from any breach of duty up to this point in time.

5.11    When Mr Smith consulted Dr A on 29/10/2014, he was complaining of a several month history of persistent cough. He also had a lifelong history of smoking. The records also documented that he had been complaining of haemoptysis for well over two months, on the two previous presentations. Despite these facts, Dr A failed to enquire about haemoptysis according to the medical records. The presence or absence of haemoptysis in a patient with a smoking history and a persistent cough, who had complained of it at his two previous consultations, is a vital part of the history and I would have expected any competent general practitioner to have made this enquiry and documented the result of it. It is my opinion that no responsible body of general practitioner opinion would support Dr A’s failure to make that enquiry on that date.

5.12    Had Dr A made the appropriate enquiries on 29/10/2014, I strongly suspect that, bearing in mind the fact that haemoptysis was present on 19/08/2014, 24/09/2014, and 10/11/2014, it would also have been present on 29/10/2014. This would have been the third date upon which Mr Smith had complained of haemoptysis, over a course of more than two months. This would most definitely have reached the threshold for an urgent referral for suspected cancer according to the NICE criteria.

5.13    Had Dr A made the appropriate enquiries on 29/10/2014, and those enquiries had revealed persistent haemoptysis, it is my opinion that any competent general practitioner would have made an urgent fast-track referral for suspected cancer to a respiratory physician on that date.

5.14    Had Dr A made an urgent referral for suspected cancer on 29/10/2014, then I would have expected Mr Smith to have been seen in the respiratory clinic by 13/11/2014, some seven and a half weeks prior to the date that he was actually eventually seen in the respiratory clinic.

5.15    When Mr Smith consulted Dr B on 10/11/2014, he had a history of persistent cough and haemoptysis which had been going on for up to three months, and had failed to respond to treatment with antibiotics and inhalers. His presentation therefore reached the threshold for urgent referral for suspected cancer according to the NICE criteria. Dr B failed to make such an urgent referral, making a routine referral instead. It is my opinion that no responsible body of general practitioner opinion would support Dr B's failure to make an urgent referral on that date.

5.16    Had Dr B made an urgent referral for suspected cancer on 10/11/2014, then I would have expected Mr Smith to have been seen in the respiratory clinic by 25/11/2014 at the latest, some six weeks before he was eventually actually seen.

5.17    I recommend that the Claimant’s solicitors seek the opinion of a consultant respiratory physician or a consultant clinical oncologist on the issue of whether or not these delays in Mr Smith receiving specialist attention would have had a causative impact upon his prognosis. I would caution that, as the delay was relatively short, its causative impact is likely to have been small, although this is clearly a matter for the respiratory physician or oncologist to offer definitive opinion on.

5.18    In summary then:

• I make no criticism of the GPs involved for failing to refer Mr Smith for suspected cancer based on the CT report of November 2013 and his recurrent cough.
• Dr A’s failure to conduct adequate enquiry on 29/10/2014 was unacceptable and resulted in approximately a seven and a half week delay in Mr Smith receiving specialist attention.
• Dr B’s failure to refer Mr Smith urgently on 10/11/2014 was unacceptable and resulted in approximately a 6 week delay in Mr Smith receiving specialist attention.

I understand my duty as an expert witness is to the court. I have complied with that duty and will continue to comply with it. This report includes all matters relevant to the issues on which my expert evidence is given. I have given details in this report of any matters which might affect the validity of this report. I have addressed this report to the court. I further understand that my duty to the court overrides any obligation to the party from whom I received instructions.

I confirm that I have no conflict of interest of any kind, other than any which I have already set out in this report. I do not consider that any interest which I have disclosed affects my suitability to give expert evidence on any issue on which I have given evidence and I will advise the party by whom I am instructed if, between the date of this report and the trial, there is any change in circumstances which affects this statement.

I confirm that I am aware of the requirements of Part 35, Practice Direction 35, and the Guidance for the Instruction of Experts in Civil Claims 2014.

I confirm that I have made clear which facts and matters referred to in this report are within my own knowledge and which are not. Those that are within my own knowledge I confirm to be true. The opinions I have expressed represent my true and complete professional opinions on the matters to which they refer.

Dr Thomas William Caudell, BM, MRCGP

General Practitioner

GMC No 6074182

Dated: 01/12/2016

Glossary of technical terms

List of documents I have examined

The claimant’s GP records

Instruction letter from Jones & Jones

Chronology prepared by Jones & Jones

Report of Dr Y, consultant cardiologist

References

1. National Institute for Health and Clinical Excellence. Referral guidelines for suspected cancer – Quick reference guide. June 2005.

My experience and qualifications

Education

• University of Southampton School of Medicine: 1998-2003

Key Qualifications

• Bachelor of Medicine (BM, Southampton): 2003
• Membership of the Royal College of General Practitioners: 2009
• Certificate of Completion of Training in General Practice (PMETB): 2009
• Bond Solon Excellence in Written Evidence Course: 2012
• Bond Solon Courtroom Skills Course: 2016

Expert Witness Accreditations

• AvMA Expert Panel
• APIL Expert Panel
• Legal Hub Expert Panel
• General Medical Council approved expert witness for professional regulation & Medical Practitioners Tribunal Service matters

Employment

Current Roles

1) GP Principal & Partner, Talbot Medical Centre, 63 Kinson Road, Bournemouth. BH 10 4BX.

2) Medical Expert Witness.

3) GP Appraiser, NHS Health Education Thames Valley & Wessex

05.08.2009-30.09.2010: Locum General Practitioner, Bournemouth & Poole PCT.

06.08.2008-04.08.2009: Registrar in General Practice. Talbot Medical Centre, 63 Kinson Road, Bournemouth. BH10 4BX.

06.02.2008-05.08.2008: GP Specialty Registrar 2 in Oncology & Palliative Medicine. Poole Hospital, Longfleet Road, Poole. BH15 2JB.

07.11.2007-05.02.2008: GP Specialty Registrar 2 in ENT. Poole Hospital, Longfleet Road, Poole. BH15 2JB.

01.08.2007-06.11.2007: GP Specialty Registrar 2 in Orthopaedics. Poole Hospital, Longfleet Road, Poole. BH15 2JB.

05.07.2006-30.07.2007: Senior House Officer, Anaesthetics. Poole Hospital, Longfleet Road, Poole. BH15 2JB.

01.01.2006-11.04.2006: Registrar, Emergency Medicine. Joondalup Health Campus, Shenton Avenue, Joondalup, WA 6027, Australia.

19.09.2005-31.12.2005: Resident Medical Officer, Emergency Medicine. Joondalup Health Campus, Shenton Avenue, Joondalup, WA 6027, Australia.

04.05.2005-04.09.2005: Senior House Officer, Accident & Emergency. The Royal Bournemouth Hospital, Castle Lane East, Bournemouth. BH7 7DW.

02.02.2005-03.05.2005: Senior House Officer, Medicine & Intensive Care. The Royal Bournemouth Hospital, Castle Lane East, Bournemouth. BH7 7DW.

04.08.2004-01.02.2005: Senior House Officer, Accident & Emergency. The Royal Bournemouth Hospital, Castle Lane East, Bournemouth. BH7 7DW.

04.02.2004-03.08.2004: Pre-Registration House Officer, Colorectal, Upper GI, & Orthopaedic Surgery. University Hospital Southampton, Tremona Road, Southampton. SO16 6YD.

06.08.2003-03.02.2004: Pre-Registration House Officer, Cardiology/Acute Medicine. The Royal Bournemouth Hospital, Castle Lane East, Bournemouth. BH7 7DW.

Statement of Experience

• I qualified in 2003 and became a Member of the Royal College of General Practitioners in 2009. I have been a full-time partner at a large NHS teaching practice in Bournemouth since 2010, before reducing to three-quarter time in 2016, where I share responsibility with my partners for:

• the provision of Primary Medical Services for a population of around 25,000 people
• clinical governance and the meeting of quality and outcome framework targets
• teaching medical students from the University of Southampton School of Medicine.

• provision of minor surgery
• musculoskeletal medicine including joint and per-articular injections
• fitting of sub-dermal contraceptive implants
• training GP registrars (I am an approved GP trainer).

• chaired a working group to develop best practice guidelines in the provision of joint and peri-articular injection therapy for Dorset,
• chaired the Dorset fractured neck of femur pathway group,
• sat on the working group to determine spinal pain care pathways for Dorset.
• sat on the Dorset CCG musculoskeletal clinical commissioning committee.

• I am a GP appraiser, responsible for helping my appraisees meet the requirements for revalidation.
• Prior to becoming a GP I worked in Orthopaedics, Accident and Emergency Medicine, Anaesthetics, Intensive Care, Cardiology, Acute Medicine, General Surgery, Ear Nose and Throat, Palliative Medicine and Oncology.
• I am familiar with Part 35 of the civil procedure rules, and the requirements of solicitors when seeking expert evidence. I have undertaken appropriate expert witness training. My expert witness workload includes both Claimant and Defendant work, although Claimant work predominates. I also undertake work for the GMC in professional regulation cases.