Disputing gluten – did a rural GP miss the signs of coeliac disease?

18 January 2024

A District Court judge found that Dr Yaramati, a GP practicing in a small rural town in the NSW Riverina, did not breach his duty of care by failing to diagnose his patient with coeliac disease throughout numerous consultations between 2015 and 2020.

Barry Nilsson’s Sydney health law team acted for Dr Yaramati in the proceedings.

In issue

  • The plaintiff, Mr Michael Curran, claimed damages in the District Court of NSW against the defendant, Dr Veerendra Giri Yaramati, alleging he breached his duty of care by failing to diagnose and treat coeliac disease between 2015 and 2020.
  • The plaintiff alleged that the defendant failed to: investigate the cause of diarrhoea, weight loss and abnormal blood test results; order coeliac serology. The plaintiff claimed that he suffered from injuries and ongoing disabilities including: chronic diarrhoea; orthostatic hypertension; increased risk of cancer; osteoporosis; chronic malaise; chronic malnutrition; and weakness and falls.
  • The defendant denied liability and relied on section 5O of the Civil Liability Act 2002 (NSW) (CLA). This was the first case in Australia that considered the longitudinal application of section 5O, where the subject consultations ranged over a 5-year period.

The background

The plaintiff was born in April 1947 and was nearly 76 years old at the commencement of the final hearing. He was a retired jockey and horse trainer and was living and working as a caretaker on a farm in the New South Wales Riverina region. The closest town, Urana, had a population of around 300 and one general practitioner, Dr Yaramati (the defendant).

The plaintiff consulted with the defendant for the first time on 23 January 2015, where he reported urinary problems. The defendant undertook a wide range of blood tests and provided a referral to a urologist. Further investigations led to a diagnosis of metastatic prostate cancer in April 2015.

The blood tests dated January 2015 initially revealed a low serum folate level but normal red cell folate levels and mildly low B12 levels. A repeat blood test in December 2015 showed a similar yet slightly improved pattern. The defendant continued to consult with the plaintiff to administer androgen-deprivation injections, monitor his blood test results and provide him with vitamin and mineral supplementation.

The plaintiff first complained of diarrhoea to the defendant in July 2016. This was after the plaintiff worked with a pump in dirty water. From 2016, on various occasions, the plaintiff reported having erratic bowel function with intermittent diarrhoea (at times with rectal bleeding) to the defendant, his treating urologist, oncologist and Wagga Wagga Base Hospital. The plaintiff also continued to have urinary issues.

The plaintiff underwent colonoscopies between 2017 and 2019, performed by a urologist to investigate symptoms of rectal bleeding and was diagnosed with radiation proctitis, secondary to his prostate cancer treatment. No specialist had raised the issue of coeliac disease at this point.

In 2019 and 2020, the plaintiff was admitted to Wagga Wagga Base Hospital on several occasions with severe illness including urosepsis. On 29 August 2020, during one of these admissions, the plaintiff had biopsies taken during a colonoscopy, which showed findings compatible 'inter alia with partially managed coeliac disease'. However, the defendant did not receive a copy of these results until over a year later, when the plaintiff was no longer his patient.

On 15 December 2020, the plaintiff saw a new GP and reported recurrent episodes of diarrhoea and hypokalaemia requiring hospitalisation. The GP ordered a coeliac serology test, which confirmed a diagnosis of coeliac disease. The plaintiff was then advised to commence a gluten-free diet.

The decision at trial

Dicker SC DCJ found that the plaintiff was an honest albeit unreliable witness, noting that he had a very poor recollection of his medical consultations, hospitalisations and symptoms during the relevant period. Notably, the plaintiff did not recall undergoing major surgeries, significant hospitalisations and self-catheterisation. His Honour therefore concluded that the contemporaneous records and notes, including those of the defendant, should be preferred over the plaintiff’s recollections.

His Honour generally preferred the defendant’s experts.

In relation to breach, His Honour considered the s 5O issue. The defendant relied on evidence from Dr Christopher Pitt (general practitioner).

The plaintiff challenged the s 5O pleading and submitted that the evidence of Dr Pitt did not support the pleading. The plaintiff submitted that Dr Pitt, in his report and during his evidence on the voir dire, failed to clearly make the distinction between s 5O and the general breach provisions under s 5B and s 5C of the CLA. Furthermore, it was submitted that Dr Pitt sought to make a holistic assessment of the defendant’s management over many years of consultations, rather than dealing with each individual consultation.

His Honour stated that it was unclear how s 5O could apply in these circumstances and neither party were able to direct him to any previous authorities. He considered Dr Pitt’s conclusion to be too general to be persuasive and he had difficulties seeing how a 'summary conclusion' can be usefully applied to such a lengthy series of consultations spanning over 6 years. Further, he was not satisfied that Dr Pitt appreciated the difference between the requirements under s 5B and s 5O of the Civil Liability Act.

It was found that a defence under s 5O was not established but the defence was successful under s 5B. His Honour preferred the evidence of Drs Pitt and Vickers and found that a reasonable GP in Dr Yaramati’s position would not have recommended coeliac serology testing from 2015 to October 2020. He also did not consider it was reasonable for Dr Yaramati to refer the plaintiff to a gastroenterologist. No breach of duty of care was found.

In relation to causation, His Honour said if he was wrong on his finding that there was no breach, then the result of breach of duty depended on the specific breach. This issue was more complicated and he went through various scenarios of what could have flowed from alleged breaches at different points in time.

His Honour preferred the evidence of Dr Flecknoe-Brown on issues of pathology results and testing and found that coeliac disease would have been apparent on testing if it was done in 2015 and 2016. He also accepted Dr Flecknoe-Brown’s evidence that, at the time, the relevance of serum folate versus red cell folate was well known in the pathologist community but was not reflected in comments attached to pathology results. He preferred the defendant’s experts and concluded that Dr Yaramati would have placed greater weight on the red cell folate, given the pathologist’s reports did not reflect Dr Flecknoe-Brown’s evidence. It was reasonable for Dr Yaramati to follow the pathologist’s comments.

In relation to diarrhoea, it was accepted that the plaintiff’s diarrhoea was episodic, and it was reasonable to consider the cause was radiation proctitis at least for some period of time. The alleged 18-month history of diarrhoea was not reflected in the plaintiff’s evidence and was inconsistent with what Dr Yaramati was told. Notably, no specialist had raised or referred to any issue of coeliac disease until 2020.

In relation to the weight loss, His Honour concluded that there was no unexplained weight loss. Dr Flecknoe-Brown’s evidence was rejected on this issue, as it was inconsistent with the medical records. His Honour found that the rectal bleeding was more likely explained by radiation proctitis and colonoscopy findings. The electrolyte imbalance, anaemia and osteoporosis were fluctuating, and more likely age-related or the result of hormonal treatments. These issues could not have been avoided. The alleged falls associated with coeliac disease were deemed to be mechanical in nature rather than a result of balance problems referable to untreated coeliac disease.

Regardless of any breach, His Honour found that the plaintiff would still have had urinary issues in 2015, prostate cancer in 2015, testing, radiation therapy, radiation proctitis, inflammation, rectal bleeding, androgen deprivation therapy, cancer treatment, Prolia injections, some diarrhoea, colonoscopies, kidney stones and blockages, and possibly the infections in 2020.

Although it was not necessary to do so given the findings on breach of duty, His Honour nevertheless calculated damages in case he was in error, but stated that this was a difficult task as damages depend on what breach was found. There was no evidence served by the plaintiff to support past out-of-pocket expenses. Damages were assessed in the amount of $52,710.

Implications for you

Insurers and lawyers will need to consider how best to instruct liability experts to deal with s 5O of the CLA, particularly in cases where the alleged breach of duty occurs over many years. A breach expert should provide a detailed conclusion regarding their views on s 5O – a holistic approach is not appropriate. In consideration of this decision, it may be that despite any attempt by an expert to dissect the issue, unless they provide a lengthy report (probably upwards of 100 pages in this case) to consider each and every single consultation, it will still be inadequate to meet the s 5O requirements. It may be that s 5O can’t be successfully applied to matters with consultations spanning over a number of years, and thus only s 5B and 5C need to be considered. Particular focus will therefore need to be applied to ensure the expert addresses all of the relevant sections.

Curran v Yaramati [2023] NSWDC 546

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