Summary
Ms C, who works for the Patient Advice and Support Service, brought the complaint on behalf of Ms A. It concerned the delay in Ms A's son's diagnosis with Hodgkin's Lymphoma (a cancer that develops in the lymphatic system).I decided to issue a public report because of the significant personal injustice suffered by the child and his family in delaying the diagnosis. I was also concerned that this case highlighted a potential systemic failure at the GP practice to recognise a 'red flag' symptom of cancer.
The child was taken to the practice in May 2013 with a painful swelling on the left side of his neck. He was seen by a doctor who took blood for testing and prescribed an antibiotic. The child returned to the practice later that month and was seen by a different doctor. A chest x-ray referral form was completed and a note made that blood tests were to be repeated in one month as some of the earlier results were abnormal. Further antibiotics were prescribed.
However, no appointment was made with the practice for the further blood tests and no chest x-ray appointment was allocated to the child at the local hospital. The child returned to the practice in October 2013 when he was seen again by the first doctor who immediately referred him for a chest x-ray and for further blood tests. Further consultations took place regarding the child's continuing pain and though a referral was made, it was not an urgent referral and the child was advised to wait for a forthcoming appointment in early November. After this appointment and following further investigation, he was diagnosed with Hodgkin's Lymphoma.
I took independent medical advice on this complaint from a GP adviser. They referred to the Scottish referral guidelines for suspected cancer and commented that they would expect a doctor to be aware of the significance of a left supraclavicular (above the collarbone) node and its potential as a sign of an underlying cancer. They said it would have been reasonable practice to refer the child at an earlier stage and considered that this delay suggested a lack of clinical knowledge on the part of the practice doctors. Although it was considered beneficial to carry out blood tests and an x-ray, the adviser said that this should not have delayed the referral being sent when the child first presented with a lump.
This case also highlighted the way referrals were processed by the practice at that time. The practice were unable to say whether the letter requesting an x-ray had been lost at the practice and never posted; lost by Royal Mail; or lost within the records office at the local hospital. They apologised for the delay in the child receiving his x-ray acknowledged that ideally, the referral should have been followed up. They said that there had not been a robust system for following up referrals or test requests.
The practice explained that in order to prevent such incidents happening again, the process had been changed so that the referring doctor now gives the referral letter to the patient and instructs them to go directly to the hospital. They also advised that a register had been introduced on their computer system for the daily recording of all referrals and test requests. They said that this is checked each week and updated with results or other information received, with any entry that has not been actioned for more than two weeks being flagged for immediate attention. They considered that the new system worked well and would prevent a recurrence of the circumstances the child experienced. I asked the adviser about the new system introduced by the practice to monitor referral and test requests and they commended it and agreed that this would adequately address the issue of the chest x-ray request that arose in this case.
I am concerned that the events in this case suggest a gap in the clinical knowledge of both practice doctors who saw the child, as neither identified the significance of the supraclavicular lump.I appreciate that one of the doctors has now retired, but the other continues to practice. It is important that this matter is addressed without further delay as a learning priority, and I made a recommendation about this.
Redress and recommendations
The Ombudsman recommends that the practice:
- issue a written apology for the delays in appropriately referring the child to the board;
- ensure that the practicing doctor identifies the diagnosis and referral criteria for signs of cancer as a learning priority; and
- ensure that this case is discussed at the practicing doctor's next appraisal.