The scene

A patient in her late 20s presented to an MDU GP member with intermittent, fresh red rectal bleeding and painful defecation during pregnancy. She had no change in her bowel habit and a history of haemorrhoids, and the GP gave her conservative treatment. Some two years later, the patient returned complaining of fatigue and constipation. Blood tests were normal and there was no concerning weight loss, and the GP prescribed a laxative for the constipation.

One month later the patient had not improved, and a rectal examination showed external haemorrhoids and an anal fissure, for which appropriate treatment was prescribed. As her symptoms persisted despite these measures, a routine surgical referral was made. The subsequent rectal examination and proctoscopy revealed a thrombosed pile and anal fissure, but no other significant findings. Treatment with topical diltiazem was prescribed and she was discharged.

Over the next few months the patient experienced increasing anal pain and bleeding, and a further colorectal referral was made. Digital rectal examination by the colorectal surgeon detected a hard mass and sigmoidoscopy showed a rectal carcinoma 8cm from the anal verge, and histology revealed a poorly differentiated adenocarcinoma. The patient underwent radiation-chemotherapy and an AP resection but was subsequently found to have widespread metastatic bone disease. She sadly died less than a year after diagnosis.

The claim

The patient's husband brought a claim against the GP, alleging they should have carried out a rectal examination and referred the patient for further investigations at her initial consultations. The claim further alleged that if this had been done, the rectal carcinoma would have been diagnosed and the patient, on the balance of probabilities, would have survived.

The MDU obtained independent expert evidence from a GP, who was supportive of the member's management at both of the consultations in question. The expert noted that symptoms of haemorrhoids are common in pregnancy, and that the majority of competent GPs would provide symptomatic treatment and avoid rectal examination in pregnant women unless absolutely necessary. The expert GP's view was that there was no indication for further investigation at any point before the patient was referred.

The MDU's claims handler also obtained expert evidence on causation from an oncologist. She noted that colorectal carcinoma in the 25-30 age group is extremely rare, with on average fewer than 80 women in this age range diagnosed annually.

The patient had an extremely rare subtype of tumour characterised by early infiltration of the submucosa, making diagnosis difficult and conferring a very poor prognosis with early metastatic spread. The tumour was not easy to detect on digital rectal examination until very late in the course of the disease. It was not found by the first consultant surgeon either, and as such even if the GP had examined early on, an obvious rectal carcinoma would not have been palpable.

Furthermore, the cancer was likely to have been present two years before the patient presented; even if she had been referred at the first consultation, the tumour would not have been diagnosed before it metastasised and the outcome would have been the same.

The outcome

The MDU offered condolences to the patient's husband but strongly denied liability in the letter of response, based on the experts' evidence and our member's contemporaneous records, and emphasising that there was no indication for further investigation or referral based on the patient's presentation.

The response pointed out that when the patient was referred to a consultant colorectal surgeon earlier in her illness, the examination and proctoscopy did not find any abnormality. The MDU also highlighted that the oncology evidence confirmed that an earlier referral would have made no difference to the patient's outcome.

A few months later, the claimant's solicitors wrote to say they were discontinuing the claim against the MDU GP member in light of the MDU's robust response.

Delayed diagnosis of rectal cancer

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