A patient in her late 20s attended her GP with a suspected urinary tract infection, for which she was prescribed antibiotics. At the end of the consultation, the patient mentioned that she thought she had noticed a lump in her left breast. The GP, an MDU member, examined her but was unable to identify any abnormality or discreet lump, and reassured the patient.
Around two years later the patient reported to a different GP that she had a lump in her left breast that had been getting bigger. On examination, this doctor found a fixed and hard lump in the left breast with associated skin changes and immediately referred the patient to hospital under the two week wait for suspected breast cancer. Histology confirmed a high grade ductal carcinoma and positive lymph nodes, and the patient underwent wide local excision with axillary clearance followed by chemotherapy and radiotherapy.
The patient brought a claim against the GP member alleging delayed diagnosis and failure to identify breast cancer. If the GP had referred the patient two years earlier, the patient alleged she would have only needed wide local excision and sentinel lymph node biopsy, avoiding the treatment and side effects of chemotherapy, radiotherapy and the symptoms of the lymphoedema in the left arm. She would also have had a normal life expectancy.
The GP called on the MDU for help. In order to respond to the allegations we instructed a GP expert to give an opinion on the standard of care provided. The expert stated that the notes on the breast examination were brief, but was supportive of the member's care on the basis that no lump was palpable.
We also asked an oncologist to provide an opinion on causation. Their view was that on the balance of probabilities, the cancer would have been impalpable two years earlier - even if the member had made a referral, the cancer could not have been detected.
The MDU served a letter of response on behalf of the member denying liability, but the claim progressed nevertheless and court proceedings began, with experts from both sides meeting to discuss the case. The patient's GP expert was critical of the MDU member for not documenting the site of the patient's reported breast lump, and reported that more adequate safety netting should have been in place to make sure that the patient knew to re-attend if her symptoms persisted.
However, the patient's breast surgeon and oncology experts were not able to convincingly set out their case that earlier referral would have led to detection of the tumour. As a result of these discussions the claim was discontinued three weeks before trial.
We were able to defend the claim because the patient was unable to prove that breast cancer was present at the time of the member's consultation. Although the member did not document the full details of her consultation, there was enough evidence in the contemporaneous records to demonstrate that a breast examination had taken place.
It is often a challenge to completely document a consultation, especially when there is more than one presenting complaint. However, it is advisable to keep full and accurate notes where possible, as this can reduce the potential for factual disputes if a complaint or claim arises.
This guidance was correct at publication 16/07/2018. It is intended as general guidance for members only. If you are a member and need specific advice relating to your own circumstances, please contact one of our advisers.