A case of syphilis, computer errors, and missed swabs

By Peter Moodie, College Clinical Advisor

18 March 2022

Category: Clinical


Health and Disability Commissioner (HDC) reports are important documents to read as they often set new benchmarks for standards of care.  Having said that, they can be rather long and very detailed. When you set out on the journey make sure that you are comfortable and well hydrated.

This case involves a classic ‘Swiss cheese’ effect whereby it wasn’t just one error but a whole series by several agencies that contributed to near disaster.  The report is long; 56 pages including appendices and the Deputy Commissioner (the Commissioner) uses a peculiar dating system, which to be polite is not intuitive: A typical date of an event is written as ‘23 Month 1’ with a later date as ‘10 Month 2’; there is no year specified. You might be tempted to interpret this as ‘23 January’ but you would be wrong because you will find that in this case the month goes up to ‘13’.  This is in fact an attempt to show a timeline of events. However, to be logical the start date should read ‘23 Month 0’! (The HDC claims it uses this system to protect privacy). In another part of the document, you will find that these events started 2018 and finished in 2019, which is a long time ago considering the important findings.

With complicated timelines I do think a visual timeline would be much more helpful.

The case involves a sexual health clinic, a medical centre, and a laboratory, ALL run by District Health Board (DHB)1. There is a second laboratory run by DHB2, which DHB1’s laboratory refers more complicated tests to.

The Case

The sexual health clinic has no patient management system (PMS) nor a computerised recall system. The service is run by one general practitioner and two nurses, four hours a week. They have no backup other than the ability to refer to the local emergency department for advice.  If the doctor is not present the clinic is run by the nurse. 

The DHB-run general practice covers a population of 5,500 patients and is run by one general practitioner and six practice nurses.  This is about three times the normal workload of a general practitioner.

Dr Peter Moodie

Both DHB laboratories software issues, both internally and when they message each other. Laboratory Two identified 14 delayed reporting events in eight months because of incorrect data entry.  To add to the confusion, Laboratory Two does not necessarily flag abnormal results, making it difficult for the general practice to easily identify important results.

Into this milieu a young person who identifies as MSM (men who have sex with men) attends the sexual health clinic after having unprotected receptive anal sex while overseas; he also complains of bleeding haemorrhoids.  He is seen by the nurse on duty (the doctor is away) who arranges for appropriate tests including HIV and syphilis but does not do an anal swab as they were not sure if they should do it given the rectal/anal bleeding.  They record in the notes that they have not done the anal swab or a throat swab but arrange for him to see the doctor the following week.

The following week the patient is seen by Dr B at the clinic and told the results of the negative tests but warned that he needs to have a repeat HIV test in two weeks.  Dr B omitted to warn him about the syphilis test and did not do the oral and rectal swabs.  Dr B explained to the Commissioner that on that day they were under very significant stress with a family crisis and was “internally anguished and distracted.”

A fortnight later Dr B saw the patient again and was again under significant stress and would have preferred to have deferred the appointment. However, there was pressure for them to continue and they did but did not organise another syphilis test for three months hence.

About three months later the patient presented to the medical centre (not the sexual health service) with classic signs of syphilis. He was correctly investigated, diagnosed, and treated but there was an 11-day delay in informing the patient of the diagnosis and him starting treatment.  This delay obviously caused great distress for the patient and was created by a series of events including: the result being initially overlooked, possibly because it was not flagged as abnormal. Further to that the practice nurse responsible then went on leave without handing over the relevant files to the practice doctor.  

There were then further delays with follow up testing because of a software glitch in Laboratory Two, which can only be followed by reading the full report.

Commissioners’ findings

As you can imagine the Commissioner was critical of Dr B for their omissions along with the general practice nurse for missing the abnormal lab test and then not handing over the results before they went on leave.  Likewise, the laboratories were identified as wanting, and the general practice was criticised for not having a formal policy about test follow up.

However, the Commissioner particularly identified that the DHB1 had breached the Code by failing to have in place adequate support for its staff and noted that “primarily the failings identified were the result of a wider systemic issue.”  There was inadequate staffing, backup, or formal reviews.

What was learnt?

Medical practice has become more complicated and often written ‘guidance’ for the management of a condition is in fact a protocol.  I don’t think that anyone of us could say that they had never forgotten to arrange an important test or overlooked an important result.  As the complexity of medicine increases, the need for computerised check lists and safety nets increases.

General practice started to computerise over 40 years ago and it is unacceptable that a DHB uses ‘financial constraints’ as an excuse for not providing a safe environment for its staff.  By failing to adequately manage its services, patients and staff are put in danger. 

Key learning points:

  1. At the end of the day unworkable doctor-patient ratios can lead to poor outcomes and GP’s will be held accountable for practice not the DHB.
  2. A general practice needs to have very clear processes for managing abnormal test results. 
  3. Nursing staff are a critical part of service delivery. However, there needs to be clear escalation path where there is the potential for working outside of competency.
  4. DHB’s need to invest in clear processes of communication with general practice as well as within themselves.