Delayed diagnosis of cancer

Cases of delayed breast cancer diagnosis illustrate how problems may arise, says MDU legal adviser Dr Karen Roberts.

According to an analysis of medical negligence claims settled by the Medical Defence Union (MDU) on behalf of GP members, malignancies (including breast cancer) are the most frequent condition GPs miss or delay diagnosing.

This is not surprising given that cancers are common diseases and that the signs and symptoms of cancer can sometimes be difficult to distinguish from non-serious conditions.

Delayed diagnosis
Of 620 claims settled by the MDU on behalf of GP members over a five-year period, delay or failure to diagnose malignancy accounted for 148 cases, of which 38 cases involved breast cancer.

Delay in diagnosis is not necessarily negligent. It is possible to defend a claim of this type against a GP successfully if the clinical management is shown to be competent and reasonable.

These two cases illustrate how cases can be settled and the kinds of problems that can arise.

Case 1: failure to refer a patient urgently
A 38-year-old woman saw her GP because she had noticed a lump in her left breast. She explained that she often had lumpy breasts before her period, but that this lump seemed larger than normal. The GP examined the woman but could not find the lump. She advised the patient to return after her next period so another examination could be carried out.

The patient did not return for another three months. This time the GP found a tender swelling in the upper left breast. The GP referred the woman to the breast clinic where she was seen four weeks later and invasive ductal carcinoma was diagnosed. The patient made a claim for the delay in diagnosis.

The GP had taken notes of the consultations and the expert opinion was broadly supportive of the steps the GP had taken, but was critical of the failure to make an urgent referral at the second attendance.

However, the delay did not make a difference to the ultimate outcome for the patient and, as a result, the claim was successfully defended.

Case 2: failure to record an examination
A patient attended with a history of localised pain in the left lower outer quadrant of her breast and although the GP could not palpate a lump she referred the patient for a mammogram because of a family history of breast cancer. The mammogram was normal.

The patient returned four months later with flu-like symptoms and at the same time mentioned that the problem had not resolved. The GP made a note of this but did not record an examination.

One year later, the patient consulted the GP complaining of a change in the skin of the left breast. The GP found dimpling and a palpable breast lump, and made an urgent referral to the breast clinic where a diagnosis of breast cancer was made. The patient brought a claim.

It transpired that the mammography report was incorrect and the cancer should have been spotted. However, the GP did not record whether she examined the patient at the second consultation, and as a result the GP expert instructed by the MDU felt there would be difficulty defending this aspect of the GP's care.

The claim was settled on behalf of the hospital where the mammography had taken place, and a contribution was made by the MDU on behalf of the GP.

Avoid system failures
Many of the cases of delay in diagnosis that the MDU sees are a result of system failures, rather than individual error.

The MDU has suggestions to minimise the risk of delayed diagnosis of malignancies.

Following thorough examination and history taking, the initial differential diagnosis and management plan need to be noted in the clinical record. If symptoms do not progress as expected, arrangements to review, and refer the patient if necessary, should be made.

The likely response time for treatment to take effect and subsequent follow-up plans should be explained to patients and recorded in their notes.

A thorough system for recording all laboratory samples and tests requested should be maintained. This should include a mechanism to check receipt and ensure results are reviewed, and that the patient has been followed up.

Protocols can be useful in setting out the standard of care to be provided and defining responsibilities within the team. It is advisable to have protocols in place, such as for dealing with test results and responding to patients. These are useful for setting the standard of care, defining responsibilities within the team, and help in the event of a claim.

A record of all consultations, including phone consultations, should be kept.

All relevant findings, whether positive or negative, should be recorded. Records are essential for good patient care and can also help protect against future claims.

The cases mentioned are fictitious, but based on cases from the MDU's files. Doctors with specific concerns are advised to contact their medical defence organisation.

Dr Roberts is a clinical risk manager at the Medical Defence Union

October is National Breast Cancer Awareness month. For more information, visit www.breastcancercare.org.uk or www.breakthrough.org.uk

How to avoid a delayed diagnosis
  • A full history and examination should be undertaken, and a record kept.
  • All patient contacts should be recorded, including advice given over the telephone or on home visits.
  • Procedures should be in place to follow up patients you are concerned about to ensure they return for review.
  • A system for recording the request of laboratory samples and tests, their receipt and review should be maintained.
  • If an examination or test result causes suspicion, consider referring for an urgent investigation.

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