ࡱ> 7 nbjbjUU 27|7|bal'''8'<$(h((("))))) *6888888$ ?d\*))**\.))q...*p))6.*6.>.6ځ")( p.!'*rH"0h.". HYPERLINK "http://www.coventrydoctors.org.uk/feltbower" Click here to return to Main Menu Title of action: Mrs Smith v- Dr Brown Court reference number: 123456 GP Expert Witness Report for Disclosure re Mrs Smith v- Dr Brown dob: 16.5.54 by Dr. A.R.Feltbower MB BChir DRCOG AFOM General Medical Practitioner 41 Westminster Road Coventry. CV1 3GB Tel 024 76223565 Fax 024 76230053 Email: Tony.Feltbower@nhs.net at the request of Brain and Brace Solicitors consisting of 22 pages dated 7th March 2003 Contents Section Page Introduction summary of my conclusions 3 Key Issues to be addressed and statement of instructions 5 Background 6 My opinion 7 Statements of compliance and truth 11 Appendices My experience and qualifications 12 Documents I have examined in producing this report 13 Relevant Chronology 14 Glossary of technical terms 20 References 22 1. The writer I am Dr Tony Feltbower, a full-time general medical Practitioner. Full details of my qualifications and experience are in appendix 1. These entitle me to give an expert opinion. Summary of the case The case concerns an allegation that there was a failure to make an earlier referral for treatment of Endometriosis, resulting in more extensive treatment / surgery than might otherwise have been necessary, and that inappropriate prescriptions were issued for combined preparations of Hormone Replacement Therapy (HRT) resulting in unnecessary side-effects. 1.3 There is a chronology of key consultations at Appendix 3. 1.4 I have been asked to provide an opinion regarding the standard of care provided to Mrs Smith by Dr Brown, and whether she should have been referred any earlier for further investigation, and whether the prescriptions issued for HRT were appropriate. Summary of my conclusions This report will show that in my professional opinion: If the Claimants evidence is accepted, Dr Brown has provided sub-standard care and fallen short of the standard expected of GPs in not referring for a Gynaecological opinion to confirm or exclude endometriosis. If Dr Browns evidence is accepted, in that the only symptoms presented to him had only been present for a short time, and on detailed questioning he was not made aware of any symptoms being present for more than a few months, then although his record-keeping is sub-standard, and his examination sub-standard, his management may have been acceptable, provided he advised the Claimant to return if symptoms did not improve. There was no indication for continued prescribing of a combined or cyclical preparation of HRT after January 1999. Any prescriptions that were issued for an HRT containing progestogen after this date represent sub-standard care. The Parties involved in the case are as follows Mrs Smith Complainant Dr Brown Defendant Brain and Brace Solicitors for the Complainant Dr A R Feltbower GP Expert Witness at the request of the Complainant Technical Terms I have indicated any technical terms initially in bold type. I have defined these terms when first used and included them in a glossary at Appendix 4. I have also included at Appendix 5 extracts of published works I refer to in my report. Key issues to be addressed and Statement of Instructions Mrs Smith presented to Dr Brown with abdominal pain that turned out to be due to Endometriosis. She was not referred until 3 years later, and eventually had a hysterectomy because of the severity of her condition. The allegation is that Dr Brown should have referred 3 years earlier, which may have resulted in a more conservative form of treatment. Following the operation, a combined form of HRT was prescribed by Dr Brown for more than 6 months (as advised by the hospital specialist) instead of switching to an oestrogen -only preparation. As a result of this, she suffered unnecessary side-effects. I have been asked to provide a GP Expert Witness opinion regarding the standard of care provided by Dr Brown on 13.3.95, particularly whether he should have referred at that time to a Gynaecologist for a second opinion. I have also been asked to comment on the standard of care provided by Dr Brown regarding the continuing prescriptions for the combined HRT. As a GP and not a Gynaecologist, I will not provide any opinion as to any differences in outcome or prognosis if a different course of action had been taken by Dr Brown. Background This lady was found to be suffering from severe endometriosis. This is a condition, where cells that normally line the inside of the womb, are situated outside the womb, usually around the pelvic organs. With each period, these cells bleed a little bit. This can cause pain, often severe, although the condition can also be present without any significant symptoms; the degree of endometriosis does not correlate well with the severity of symptoms. These areas can then cause scarring, resulting in adhesions. Cysts can form, which gradually increase in size with the bleeding from each period. This condition is usually found in women of childbearing age between the ages of 25 - 40. It typically presents with (often increasingly) very painful periods, and is sometimes associated with sub-fertility. There are many varied symptoms associated with endometriosis. Dyspareunia is one. Taking an oral contraceptive pill can often help relieve the symptoms of endometriosis. The diagnosis can only be properly made by laparoscopy, although an ultrasound may suggest the diagnosis. When the condition is suspected, referral to a Gynaecologist should be made so that the condition can be diagnosed and treated. My opinion I note that Gynaecological symptoms were presented to the GPs in 1979, resulting in a Gynaecological referral. However, subsequent assessment by the Hospital revealed no detectable Gynaecological abnormality, and the symptoms were diagnosed as being related to her bowels, in particular, a diet deficient in fibre. Although not detailed in the chronology, there were many consultations with GPs (averaging 2-4 per year) from 1981 through to 1992. Only the ones I have detailed at Appendix 3 have any relation to possible Gynaecological symptoms. The total number of consultations during this period represents about the average for the general population. There was only 1 consultation in 1993/94. The first clear reference to a Gynaecological condition is on 13.3.95, where the GP has recorded pain in the right groin before periods. He has recorded a diagnosis of Endometriosis?. I would expect the GP to enquire about periods, length of time the problem had been present, any other Gynaecological symptoms (eg abnormal bleeding, vaginal discharge, pain on intercourse, urinary/bowel function, contraception) and then to record relevant facts. There is no record of length of history, any examination or investigations nor as to what, if any, action was taken or advice given. An examination would be appropriate to at least include palpating the abdomen and performing an internal vaginal examination. The internal vaginal examination would be able to assess the pelvis for other signs of endometriosis (eg pelvic organs being tender, fixed in position by adhesions, cysts, pain), as well as checking for any other pelvic pathology. This should be recorded in the notes. The standard of record keeping at the consultation is poor and below that expected of GPs because there is no detail of relevant questions nor examination. Mrs Smith states that her symptoms had been present for 12-18 months and that they were getting worse. She experienced pain with intercourse. She continues that no detailed history was taken, no abdominal examination was carried, nor an internal vaginal examination. If this is correct, this represents sub-standard care. Dr Brown states that, as he cannot recall the consultation, his normal practice would have been to have asked appropriate questions and to have recorded any answers that caused him concern. He does not state that he would have asked about dyspareunia. He states that he examined thoroughly but did not undertake a vaginal examination as he did not believe it was clinically indicated. I disagree: presentation of cyclical pain for even a few months, especially where there has been a previous history of an ovarian cyst, requires a vaginal examination. Dr Brown continues to state that he wished to initially adopt a conservative approach to see if symptoms settled. However, if symptoms had been present for 12-18 months, I do not believe this was reasonable a referral should have been made (see para 3.13 above) which is likely to have resulted in earlier investigation, diagnosis and treatment. If symptoms had only just presented over 1-2 months, then it would have been reasonable to adopt a wait and see policy, with specific advice to return if symptoms did not settle, of if they became worse. If only mild, and present for a few months only, then this could be acceptable, provided a vaginal examination had been carried out to detect any pelvic pathology. I am unclear as to what diagnosis Dr Brown refers to in para 15 of his statement. If he suggests that he had made a diagnosis of endometriosis, then he should have referred to a Gynaecologist anyway. However, he suggests that his record of endometriosis? was only an aide memoir. If so, then I cannot find any specific diagnosis to which he can refer. If Mrs Smith had returned within a few months, her symptoms not having settled, then a referral to a Gynaecologist would have been expected (see above 4.24) resulting in earlier investigation diagnosis and treatment. The records are unclear as to what prescriptions were issued for HRT and when. The only clear references are to Premique being prescribed on 30.6.98 following her hysterectomy, and then a note on 19.1.01 that she had been changed to Premique cycle. Following a hysterectomy, it is not normally necessary for a woman to require the progestogen content of an HRT preparation as it is only needed to control any menstrual bleeding and to reduce the risk of causing cancer of the uterus. However, for Mrs Smith, it was twice advised by the Gynaecologist (in letters dated 22.6.98 and 22.9.98) to take a combined preparation after the hysterectomy to reduce the risk of a recurrence of endometriosis. It was recommended that it should only be prescribed for 6 months. Although there are regular consultations with the GPs following the hysterectomy, there is no indication as to when or why Premique cycle was prescribed. I note that in the letter dated 22.9.98 the Gynaecologist suggests that Evorel Combi / Evorel should be prescribed. There is also the suggestion in the GP notes that a prescription for Evorel Combi was issued. It is unclear to me any reason for the change, as it appears that she was already on Premique, having had a 3 month prescription on discharge from hospital in June. The GP consultation on 18.12.98 is also confusing as a reference is made to Premique, whereas the above comments suggest that she was taking Evorel Combi. However, it is at this consultation that further prescriptions for HRT should only have contained oestrogen according to the advice from the hospital. In issuing further prescriptions for a combined HRT, Dr Brown has provided sub-standard care. The nurse consultation on 14.5.99 for an HRT check does not state what prescription was issued this represents sub-standard care. The consultation with the GP on 18.1.00 only mentions Premique. Statements of compliance and truth I understand that my duty as an expert witness is to the Court. I have complied with that duty. This report includes all relevant matters to the issues on which my expert evidence is given. I have given details in this report of any matters that might affect the validity of this report. I have addressed this report to the Court. I confirm that insofar as the facts stated in my report are within my own knowledge I have made clear which they are and I believe them to be true, and that the opinions I have expresses represent my true and complete professional opinion. Dr Tony Feltbower. date Appendix 1 Qualifications MB BChir LRCP MRCS 1978 Diploma of the Royal College of Obstetrics and Gynaecology 1982 Associate of the Faculty of Occupational Medicine 1991 Cardiff University Expert Witness Certificate 2003 Post-registration Experience GP Clinical Assistant in Accident/Emergency 1984-88 GP Clinical Assistant in Rheumatology 1988-91 GP Clinical Assistant in Gynaecology 1983-96 Present Positions Full-time GP Principle since 1982 Member Coventry Local Medical Committee Member of Professional Executive Committee of Coventry Primary Care Trust Employment Medical Advisory Service Appointed Doctor under 'Asbestos', 'Lead at Work' and 'Ionising Radiation Regulations' for a number of local companies. Occupational Health Medical Officer for Coventry City Council since 1997 and many other local companies since 1992 Clinical Complaints AdviserClinical Complaints SAdC to the Medical Defence Union AVMA registered Registered with UK Register of Expert Witnesses Recognised by the Law Society as a Single Joint Expert I have written over 3000 personal injury reports on behalf of claimants and defendants since 1994, largely as a Single Joint Expert in recent years. I have written over 250 medico-legal negligence reports, almost 50-50 for claimants and defendants. Appendix 2 I confirm that I have received and read the following documents: Copies GP records Letter of instruction Brain and Brace, Solicitors dated 8th November Witness statement Elizabeth Smith, dated 19.10.02 Witness statement Dr Brown, dated 17.10.02 Appendix 3 Relevant Chronology 7 2 78 - new patient. Age 23. Reference to Tonsillectomy - 1973. Cyst on right ovary - 1977. Caesarean section - 1977. No serious illnesses reported. No drugs: On Minilyn 22 2 78 - problems with menstrual cycle reported. No period for eight weeks then very heavy periods. 23 10 78 - abdo pain/feeling sick. No diarrhoea Rx Minilyn 10 7 79 - Eugynon 30 6/12 5 10 79 - only had two periods since coming off the pill. Painful intercourse 10 10 79 - 2/12 pain last ????? All the time. No vomiting Ache all the time. Painful having intercourse. Tender hypochondrium and R iliac fossa. No urinary symptoms 1977 R ovarian cystectomy when 18/52 pregnant ( refer 25 October 1979 - letter to Claimant's GP (Dr Brown) from Mr Gray, Consultant Gynaecologist who states: "Thank you for your letter about this patient and her abdominal pain. On examination I could detect no gynaecological abnormality to account for this. I have initially arranged for a full blood count to be performed together with an MSU to be cultured. I have also arranged for a bran diet as she has a rather infrequent bowel action. She will be reviewed in one month." 3 8 84 - symptoms of stomach ache/backache/vomiting etc Solpadeine x40. Metoclopramide 10mg x21 11 10 87 - symptoms of back/neck/leg ache/dizziness. Rx Co-Codamol 5 1 89 Cx smear performed. Urine - NAD 2 5 89 - pain reported in knee and groin with some swelling and crepitation Rx Naproxen 18 5 89 Repeat script for Naproxen 13 3 95 - painful right groin before period. Endometriosis?. 18 1 98 - painful periods along with clots + day 1 Aged 43 . regular 5/7 Ponstan forte x100 ( Smear + PV ??? 98 Routine smear taken Referred Harris ( BGH 21 April 1998 - letter to Dr Brown (GP) from Mr R E Harris, Consultant Gynaecologist which states: "Thank you for referring your patient, who tends to get severe pain across her back and lower abdomen and right iliac fossa, radiating to the right leg. It is present about three months out of every four and her periods although she said they weren't heavy, she then said they had quite a lot of clots. Her cycle length is fairly regular, every 28 to 34 days and she has been admitted recently with some dyspareunia. She gets an occasional inter-menstrual blood loss. She has had a negative smear. She had ovarian cyst previously removed during pregnancy by my colleague Fred Bassett. She smokes 20 cigarettes a day and has had three children, one by caesarean section. On examination today, she is moderately overweight. She has a mid line abdominal scar. The uterus is anteverted, normal size and mobile. Straight leg raising was fairly normal. There was a bit of reduction on the right side and hip rotation was also normal on both sides. She was, however, markedly tender over the right sacro iliac joint and I think she does have some possible sacro-iliac dysfunction associated with her menorrhagia. I am bringing her in to laparoscope her to make sure that she does not have anything like endometriosis and we are checking her for blood count and ESR. 28 May 1998 - letter to Dr Brown (GP) from Mr Harris (Consultant Gynaecologist) "Your patient attended the pre-admission clinic on 21 May 1998, for a pre-operative assessment. She underwent a diagnostic laparoscopy and D&C today, trying to find the cause of her low back pain and heavy periods. She had a right sided hydrosalpinx which I am not sure is the cause of her pain. Her right ovary was slightly cystic and scarred. Her left ovary was stuck to the pelvic side wall and the Pouch of Douglas with what appeared to be endometriosis as was the left tube. There were areas of brown pigmentation within the left pelvic side wall and the left utero-sacral ligaments. The liver and gall bladder looked normal as did the caecum. She does appear to have some endometriosis and we will consider offering either pelvic clearance or drug treatment although I am not sure that this will cure her low back problem. We live in hope." 9 6 98 - c/o RIF pain worse today. Severe ( ??? down R anterior thigh. Also PV discharge today. Had laparoscopy + diathermy/laser to endometriosis 10/7 ago. Abdo tender ++ RIF. BS normal. Also urinary symptoms - "??? ??" no dysuria PV. V tender ++. Admit Gynae. 15 June 1998 - letter to Dr Brown (GP) from Dr N Parks - Registrar in Gynaecology to Mr M W Gray. "This lady was admitted on 9 June 1998 having had a laparoscopy on 28 May 1998. She had not been feeling well for two days with abdominal pain and a green discharge. On examination she was mildly tender across the lower abdomen and she did, indeed, seem to have a yellow, thick discharge. She was started on IV antibiotics because her temperature was 42 C. Her temperature soon settled to 36.1 C. She was changed to oral antibiotics and discharged home when the pain had settled." 20 6 98 - Med 3 8/52 Abdo pains (from 9/6) 22 June 1998 - letter to Dr Brown (GP) from Dr Richards, Senior Registrar in Gynaecology, which states: "Elizabeth came to the pre-op clinic on 18 June 1998 and subsequent had a total abdominal hysterectomy and bilateral salpingo-oophorectomy, the indication being severe pelvic endometriosis and right hydrosalpinx. The finding suggested that the right tube was moderately swollen and stuck to the Pouch of Douglas and to the uterus. The left ovary was cystic and densely adherent to the Pouch of Douglas and back of the uterus and bowel. The bladder was adhered to the uterus anteriorly. Fine dissections were made to release the adhesion. Subsequently she had a routine TAH and BSO. If she does well, she will be charged on the fifth post-operative day to be seen in two months time. We will put her on continuous combined HRT on discharge which should be changed to oestrogen only HRT after six months." 30 6 98 - TAH,BSO - on combined HRT 6/12 because of endometriosis ( Premique 3/12 20 6 98 - discharge continues - brown and smelly ( Co-amoxiclav 375mg tds (21) Metronidazole 400mg tds (21) 22 September 1998 - letter to Dr Brown (GP) from Dr J Bull, SHO in Gynaecology to Mr R E Harris. "I reviewed this lady in clinic today. As you know, she has had a hysterectomy. She tells me that since discharge, she has had one episode of UTI which has settled with antibiotics. At the moment she is having some dysuria but only first thing in the morning. On examination there was nothing to find that was abnormal on abdominal examination. Speculum examination showed that the vault had healed well. After discussion with the Registrar it was decided to start her on Evorel Combi for a further three months and then to suggest that perhaps she could switch to Evorel patches. No further follow up has been arranged and we are happy to discharge her back to your care." 25 9 98 - had hysterectomy 3/12 ago. Now still complaining burning pain both groins. S/B hospital 3/7 ago - re persisting UTI TCI for ESR/FBC BP / Thrush - Sporanox 100mg od (15) Med 3 - 8/52 - Operation/complications 20 11 98 - Med 3 6/52 Still c/o L pelvic area burning O/e abdo tender spot L pelvis PV - tender spot L pelvis. No deep dyspareunia Try diclofenac retard 100mg 18 12 98 - Chat re slight ?? of Premique 14 5 99 - nurse consultation - HRT check "all well". 29 7 99 - gastro-enteritis. 18.1.00 repeat script for Premique 9 6 2000 - pain lower abdomen/hip ( knee. No dysuria Bowels OK Not unwell. Groin - tender over obturator insertion Obturator tendonitis Discussed. Rx Try ????? 75mg I bd + Kapake 4/52 - ?steroid injection 23 11 2000 - ?????? from pain o/e back & leg movement - nil = told abdo adhesions painful bust - mastalgia No lump - ?reaction to Oestrogen - told to take pain killer 1 12 2000 - lower abdo pain and from loin Pyrexia 99 - sweaty and clammy =mane ( LHB Cephalexin 500mg 14 5 12 2000 - bellyache lower abdomen tender lower back/hips shooting pain down leg. Bowels nad Not eating few weeks 19.1.01 new GP notes that following the hysterectomy, Premique was prescribed, but then changed to Premique cycle for an unknown reason. This prompts a referral to Mr Gray, Gynaecologist. 23 May 2001 - USS abdomen and pelvis. "No pelvic masses are seen. The hysterectomy and bilateral salpingo-oophorectomy are noted. Both kidneys are of normal size and appearance with no hydronephrosis. The liver, gall bladder and biliary are normal. Normal spleen. Normal pancreas and abdominal aorta. Impression: No abdominal or pelvic abnormality is seen." 29 January 2001 - letter to GP (Dr Brown) from Mr Gray (Consultant Gynaecologist) states: "I saw this lady today. She was apparently experiencing lower abdominal pains, breast tenderness and headaches which she has associated with the progesterone content of her Premique. She need only have taken the combined HRT for 6 months after her TAH and BSO in 1998. I think it would be now more appropriate to prescribe an oestrogen only preparation." Appendix 4 Glossary of medical terms Endometriosis this is a medical condition where the cells that normally line the inside of the uterus lie elsewhere inside the abdomen (usually) and with each period of a menstrual cycle, bleed a little hysterectomy operation to remove the womb Dyspareunia - pain with sexual intercourse laparoscopy keyhole surgery looking inside the abdomen with a telescope through small incisions Premique - a continuous oestrogen / progestogen preparation of HRT Premique Cycle a cyclical preparation of a combined oestrogen / progestogen HRT Evorel Combi / Evorel cyclical preparation of a combined oestrogen / progestogen HRT Minilyn a contraceptive pill Eugynon 30 a contraceptive pill Hypochondrium the abdominal area just below the ribs on the right side Iliac fossa the lower corner of the abdomen MSU mid-stream urine Solpadeine a pain killer Metoclopramide an anti-nausea pill Co-codamol a pain killer Cx - cervix NAD nothing abnormal detected Naproxen an anti-inflammatory pain killer Ponstan forte - an anti-inflammatory pain killer PV per vagina an internal vaginal examination Menorrhagia heavy periods D&C dilatation and curettage of the uterus Hydrosalpinx a cystic enlargement of a Fallopian tube Pouch of Douglas the name for the part of the pelvis situated behind and below the uterus RIF right iliac fossa BS bowel sounds Med 3 a sickness certificate for Social Security purposes TAH total abdominal hysterectomy BSO bilateral salpingectomy (Fallopian tube removal) and oophorectomy (ovaries) Co-amoxiclav an antibiotic Metronidazole an antibiotic UTI urinary tact infection dysuria painful urination vault the area at the top of the vagina TCI to come in FBC/ESR blood tests Sporanox an anti-fungal pill Diclofenac retard an anti-inflammatory pain killer Kapake a strong pain killer Mastalgia painful breasts Cephalexin an antibiotic USS ultrasound scan Appendix 5 References: Illustrated Book of Gynaecology 2nd edition; Mackay, Beischer, Pepperell, Wood p280-285 Lecture Notes on Gynaecology 5th edition; Barnes p96-98  HYPERLINK "http://www.coventrydoctors.org.uk/feltbower" Click here to return to Main Menu  Endometriosis this is a medical condition where the cells that normally line the inside of the uterus lie elsewhere inside the abdomen (usually) and with each period of a menstrual cycle, bleed a little  hysterectomy operation to remove the womb  Dyspareunia - pain with sexual intercourse  laparoscopy keyhole surgery looking inside the abdomen with a telescope through small incisions  Premique - a continuous oestrogen / progestogen preparation of HRT  Premique Cycle a cyclical preparation of a combined oestrogen / progestogen HRT  Evorel Combi / Evorel cyclical preparation of a combined oestrogen / progestogen HRT  Minilyn a contraceptive pill  Eugynon 30 a contraceptive pill  Hypochondrium the abdominal area just below the ribs on the right side  Iliac fossa the lower corner of the abdomen  MSU mid-stream urine  Solpadeine a pain killer  Metoclopramide an anti-nausea pill  Co-codamol a pain killer  Cx - cervix  NAD nothing abnormal detected  Naproxen an anti-inflammatory pain killer  Ponstan forte - an anti-inflammatory pain killer  PV per vagina an internal vaginal examination  Menorrhagia heavy periods  D&C dilatation and curettage of the uterus  Hydrosalpinx a cystic enlargement of a Fallopian tube  Pouch of Douglas the name for the part of the pelvis situated behind and below the uterus  RIF right iliac fossa  BS bowel sounds  Med 3 a sickness certificate for Social Security purposes  TAH total abdominal hysterectomy  BSO bilateral salpingectomy (Fallopian tube removal) and oophorectomy (ovaries)  Co-amoxiclav an antibiotic  Metronidazole an antibiotic  UTI urinary tact infection  dysuria painful urination  vault the area at the top of the vagina  TCI to come in  FBC/ESR blood tests  Sporanox an anti-fungal pill  Diclofenac retard an anti-inflammatory pain killer  Kapake a strong pain killer  Mastalgia painful breasts  Cephalexin an antibiotic  USS ultrasound scan PAGE  PAGE 1 Mrs Smith v- Dr Brown 7th March 2003 report by Dr Tony Feltbower :;<]^_a0\]PQlmi}) C 忷j0JCJU 5CJ\ 5>*CJ\CJ CJH*h 5>*CJhCJhCJOJQJhOJQJaJh OJQJh0J5CJOJQJ\h$j5CJOJQJU\h5CJOJQJ\hj5CJOJQJU\h3_`a & h8 xHX d1$ *! 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