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Skipping over the details

01 September 2012

One night Mr K, a 37-year-old bricklayer, felt a lump in his testicle. Worried, he decided to attend the emergency surgery on Saturday with his wife to have it checked. When Mr K arrived at the surgery, he was seen by Dr G as his last patient. The consultation was short, only lasting a few minutes.

Dr G examined Mr K briefly and reported his finding to them as “just a little gristle that will go away with time”. He did not give any particular advice. He added that there was “nothing to worry about” and he wrote in his medical notes “testicular examination: NAD”.

Dr G appeared disgruntled that Mr K had used the emergency appointment for a routine check-up. Mr and Mrs K later reported that Dr G had appeared dismissive and tired throughout the brief consultation.

One year later, Mr K attended his GP surgery with a painless hard lump in his neck. Further investigations and referrals led to Mr K being diagnosed with a testicular choriocarcinoma. Despite treatment Mr K died two years after the diagnosis.

A claim was made against Dr G regarding his management of Mr K. The experts agreed that earlier diagnosis would have improved Mr K’s prospects and they were very critical that Dr G didn’t advise on any further follow-up or investigations; the case was therefore settled for a substantial sum.

Learning points

  • Unplanned appointments are inherently high risk, so writing good notes is even more important in this setting. On this occasion the records did not help resolve the factual dispute in the case. The medical notes should always reflect the clinical findings. If there was a palpable lump described as “gristle” to the patient, the clinical notes should have made a mention of it.
  • MPS has considerable experience of claims that have arisen from factual disputes between patients and doctors. This case emphasises the importance of making as full a note as you can, particularly if you cannot find what the patient is reporting.
  • In this case the patient presented as an emergency, which would have been taken into account in assessing the honesty of his assertion that he was acutely worried.
  • It has been recognised that delay in presentation is an important factor in men with tumours. Even if the clinical findings are clear then men should be given advice, which is documented in the notes, to seek attention again if they have any concerns.
  • Always be mindful of how human factors can affect your performance. Remember the HALT mnemonic (Hungry, Angry, Late, Tired); where possible anticipate these and take action to mitigate their impact. Where they are unexpected then be prepared to seek the opinion of your colleagues or bring patients back at the earliest opportunity to fully address their needs.
  • Most patients present with a painless, solid, unilateral mass in the scrotum or an enlarged testicle. However, it is worth being aware that there can, rarely, be a decrease in testicular size. Around one in five men with tumours will have pain at presentation. The SIGN guidance Management of Adult Testicular Germ Tumours provides advice on the diagnosis and presentation of testicular tumours. The guidelines recommend that anyone with a lump or doubtful epididymo-orchitis or orchitis not resolving within two to three weeks should be referred urgently for urological assessment.