Online doctor services are very useful for many thousands of people, but also face real problems in adequately treating people when a physical examination is not possible. There is a string of cases highlighting the importance of doctors undertaking appropriate examinations before reaching a diagnosis or prescribing: we take a look at those cases and assess what online doctors can do to ensure the safety of their patients and limit their risks.
There have been three recent cases where doctors have faced prosecution for gross negligence manslaughter after missing diagnoses that have resulted in the death of the patient. In R v Rudling  EWCA Crim 741, a GP did not undertake a Friday afternoon home visit of a boy whose mother reported a range of symptoms; she instead suggested that the boy attend the surgery on Monday morning. The boy sadly died on Saturday morning of acute Addison's disease. An expert report seen by the Crown Court suggested that she should have seen the boy to obtain a 'global sense' of his condition and as a matter of risk management. However, the Court of Appeal ultimately concluded that, while the lack of examination of the patient was serious, the information available to the doctor at the time was not enough for her to consider that the situation was life threatening, and she was acquitted.
In R v Rose  EWCA Crim 1168, the defendant was an optician who failed to adequately review retinal photos of a patient's eyes which showed evidence of optic nerve swelling. If this had been noticed and escalated earlier, the patient's hydrocephalus would have been discovered. Sadly, the patient later died of the condition, which if identified earlier would have been treatable. Considering the Rudling case above, the Court considered that in order to be found guilty of gross negligence manslaughter it must be reasonably foreseeable that not adequately reviewing the retinal photographs would give rise to a serious and obvious risk of death. While she successfully appealed the original conviction and was ultimately not found guilty of gross negligence manslaughter, Ms Rose is currently suspended from practice by the General Optical Council pending a fitness to practise hearing.
Finally, the decision in R v Bawa-Garba 2016 EWCA Crim 1841 is already well known. Dr Bawa-Garba was working in a busy paediatric admissions unit when she failed to recognise that a young boy was in septic shock, despite seeing blood test results that suggested this may be the case. She also failed to reassess him after the test results or seek advice from a consultant. The Crown Court and the Court of Appeal found that, as the boy's death occurred significantly sooner because he had not received the necessary treatment, Dr Bawa-Garba was guilty of gross negligence manslaughter. In the follow-up case, General Medical Council v Bawa-Garba  EWHC 76 (Admin), the High Court found that it was appropriate to remove Dr Bawa-Garba from the medical register on the basis of the Crown Court's findings that her actions had been "truly exceptionally bad".
These cases are clearly extreme examples, however they all go to indicate the importance of considering all the relevant information when coming to a clinical decision. In particular, the Rudling decision shows the dangers of assessing patients remotely when it is not possible to conduct a physical examination. This will be a key risk for doctors working for online GP services, who may have limited information about patients, particularly if they do not have any previous medical records for the patient.
The GMC provides further guidance for doctors engaged in remote patient consultations. In particular it emphasises that a doctor must satisfy themselves that they can make an adequate assessment, and should consider the limitations of a result consultation, as well as their knowledge of the patient, when making any diagnoses or prescriptions. Doctors will need to consider carefully the risks of diagnosing and prescribing when they have not conducted a physical examination.
It is for this reason that many online GP systems limit themselves to relatively minor conditions that can be considered over the phone. However when considering any patient, even those with apparently minor conditions, online and telephone GPs will need to consider carefully what other symptoms may actually be present but not immediately obvious.