GP consultation and reviews
A woman patient in her mid-30s, with a history in her early 20s of left axillary abscesses resolved with antibiotics, presented to her GP, an MDU member, with a right breast lump, which she had first noticed two weeks earlier but was getting worse.
On examination, the GP found a firm swelling in the upper right breast, which was tender. There was no axillary lymphadenopathy. The doctor diagnosed an inflammatory swelling, made a pictorial representation in the patient's record of the lump in the right upper quadrant of the breast and, as the patient was known to be allergic to penicillin, prescribed ciprofloxacin 500 mgs twice a day. He asked her to return two days later for review.
On the patient's review visit two days later, the GP noted that the lump was still tender and showing no improvement. He arranged for her to attend for a further review in three days' time.
When the GP saw the patient again three days later, he noted tenderness under her right arm. He decided to change the antibiotics to erythromycin and arranged a further review appointment for one week later. He also initiated a referral to the local breast clinic.
A week later, the GP again saw the patient. There was no change in the lump and he advised the patient that she would be receiving an appointment from the breast clinic, but that she should meanwhile return if the lump was enlarging.
Five weeks later, the patient was seen by another GP at the practice (also an MDU member). She felt that the lump was getting bigger and noted a tender nipple. The GP arranged an urgent appointment at the breast clinic four days later.
At the breast clinic, where it was noted that she had no family history of breast carcinoma, the patient underwent mammography and an ultrasound scan of the breast. Mammography revealed a three centimetre diameter tumour with micro-calcification in the upper outer quadrant of the right breast, and fine needle aspiration was recommended.
However, the patient refused fine needle aspiration, as she had a needle phobia, and had to be booked for a tru-cut biopsy under general anaesthetic three weeks later. The tru-cut biopsy confirmed invasive ductal carcinoma of high grade.
Some three and a half months later, following chemotherapy, the patient underwent a right Patey mastectomy and right axillary dissection and required post-operative radiotherapy.
Four months after initial surgery, the patient was re-admitted to hospital and ultrasound scan revealed massive disease infiltrating the whole of the breast and down on to the chest wall. She died a few days later.
Allegations and opinions
The patient's husband issued a letter of claim alleging negligence against his partner's GP on two main counts. First, breach of his duty of care, in that any responsible practitioner would have referred the patient to the breast clinic at the first consultation; and second, a contribution to the cause of her death, in that the delay in referring the patient for specialist care allowed the disease to spread and contributed to her unfortunate poor outcome.
The MDU obtained a GP expert opinion in respect of the breach-of-duty issue.
The GP expert advised that the GP was not in breach of his duty of care towards the patient when she first consulted him. He noted that the GP records were handwritten, comprehensive and included a full history. Further, that the patient was seen without delay on the day she first telephoned about her painful breast lump and at all subsequent advised appointments.
The expert stated that, considering the patient's young age and the fact that the breast lump had only recently appeared, the GP's diagnosis of an inflammatory lump and prescription of antibiotics was entirely appropriate, competent and reasonable and that many reasonable GPs would have acted in a similar way. His actions were similarly reasonable when the patient was still tender at the second review after five days and he referred her to the breast clinic and asked to review her further a week later.
In the matter of causation, the oncology expert, who had a special interest in the treatment of breast cancer, pointed out that the patient had inflammatory breast carcinoma, a rare cancer accounting for only one to four per cent of all breast cancers and carrying a poor prognosis.
She noted that, had the GP suspected inflammatory breast carcinoma at the first appointment and made an urgent referral to the breast clinic, there may have been a two-week delay in the appointment (the target for urgent referrals), the earliest a diagnosis could have been made.
The patient's refusal to undergo fine-needle aspiration caused a further three-week delay before a biopsy was carried out and a diagnosis made – some five weeks after the first consultation.
In the event, the patient was referred to the breast clinic on her third GP visit (five days after her first), but had to wait some seven weeks before she was seen and, with the three-week wait for the tru-cut biopsy, a diagnosis was made some ten weeks after the first consultation.
In the oncology expert's opinion, this extra five-week delay made no difference to the patient's management and outcome. This could be asserted from the disease's known natural history and the extent of the disease at diagnosis. As these tumours are rapidly progressive and spread early, she advised that five weeks earlier, the tumour would not have been much smaller.
The expert further advised that inflammatory breast carcinoma is always managed by neo-adjuvant chemotherapy, to which some 70 per cent of patients have some response, although the patient unfortunately did not fall into this category and had an extremely poor response. While the axillary lymph node reduced, the mass in the breast did not and she developed massive disease infiltrating the whole breast and on to the chest wall.
In her opinion, even five weeks earlier, the patient's response to chemotherapy would still have been poor and she would still have required mastectomy, radiotherapy and further chemotherapy.
Despite the lack of any clear documentation of the actual cause of death, the clinical symptoms (deterioration and shortness of breath), the chest X-ray findings, and the liver-function and renal tests all indicated that the patient had multiple organ failure as a result of the spread of the disease. Earlier diagnosis would have made no difference to when these metastases would have developed in these organs and when their failure would have caused the patient's death.
In view of the fact that the MDU had received a supportive report in relation to both breach of duty and causation allegations, liability was denied in this case. Based on the comprehensive response to the letter of claim, the claimant's solicitors discontinued the claim.
This guidance was correct at publication 01/12/2006. 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.