Risk Management

Failure to Diagnose Giant Cell Arteritis (1999)

By Stacey Meyer, OMIC Claims/Litigation Associate, Digest, Spring 1999

ALLEGATION: Failure to diagnose giant cell arteritis in a timely manner.

DISPOSITION: Insured was the only defendant of five to receive a defense verdict at trial.

Case Summary

A 71-year-old male presented to the insured with a history of significant and long-standing vision loss in the left eye due to cataracts and a prior inflammatory process. Visual acuity was count fingers in the left eye and 20/25 in the right eye. The patient gave a history of arthritis, thus the insured checked for symptoms of giant cell arteritis and found none, although this was not documented in the chart. Upon further questioning, it was determined that the patient did have a prior history of iritis. An elevated choroidal lesion was noted in the right eye, suggesting possibly a primary choroidal melanoma or metastatic lesion to the eye. The insured recommended a B-scan and referred the patient to an internist with a subspecialty in oncology. An appointment was made with the internist for the following day, but the patient failed to keep the appointment and did not return to the insured.

A month later, the patient was admitted to the hospital for a psychiatric evaluation and diagnosed with delusional paranoid schizophrenia. Two weeks after the patient’s admission to the hospital, an ophthalmic consult was obtained. The diagnosis was bilateral blindness due to prior retinal detachments. The patient returned to the insured one week after being discharged from the hospital with NLP bilaterally. The insured noted that the optic nerves were pale bilaterally and ordered a sedimentation rate. She referred the patient to a rheumatologist who confirmed the diagnosis of giant cell arteritis by temporal biopsy. The patient eventually lost complete sight in both eyes and sued the insured ophthalmologist, the hospital, the admitting psychiatrist and internist, and the ophthalmologist who saw the patient in the hospital.

Analysis

The central issue in this case was whether the insured should have made the diagnosis of arteritis earlier. Defense experts opined that the insured could not have diagnosed giant cell arteritis at the time of the patient’s first office visit because of the lack of clinical findings. The optic nerve appeared normal at the time and no vascular abnormalities were present in either eye to suggest vasculitis. Additionally, there was nothing in the patient’s history to suggest a diagnosis of giant cell arteritis. Furthermore, the defense argued, the patient’s own failure to follow-up with the referrals made by the insured contributed to the delay in diagnosis.

The plaintiff’s experts as well as the codefendants’ experts argued that there was evidence of arteritis at the time of the patient’s first office visit and that had the insured ordered a sedimentation rate at that visit, the patient’s visual loss could have been prevented.

Risk Management Principles

This was a complex case with potentially high damages, and as often occurs when more than one defendant is involved, finger pointing became common during the trial. Unfortunately, when defendants fight among themselves and otherwise behave unprofessionally, jurors tend to believe that all the defendants are liable.

During the trial, while each of the other four codefendants criticized the OMIC insured and each other, the insured refused to cast blame and continued to focus on her own treatment of the patient in her testimony. Even when she had the opportunity to criticize the patient for not following her recommendations and referrals, the insured defended the patient’s right to refuse further testing and follow-up treatment. But in doing so, she said, the patient forfeited his right to blame the physician for a resulting delay in diagnosis.

It was this steadfast refusal to blame others and to pursue the case on the merits of whether there was in fact a breach in the standard of care that resulted in the insured being the only one of the five codefendants to be given a defense verdict. The other four codefendants, as well as the plaintiff, were assessed a portion of liability in the final judgment.