A 32-year-old bar worker, Ms D, registered with a GP practice. Over the next eight years, six references were made in her patient notes regarding the need for her to have a cervical smear test. On at least two occasions, appointments were made but Ms D did not attend, giving no explanation.
During this time Ms D complained to practice doctors, Dr B and Dr U, of symptoms including anxiety, fatigue with difficulty sleeping and symptoms of upper respiratory tract infection.
Antibiotics were prescribed. Over the next two years Ms D experienced stress-related disorders.
Eleven years after registering at the practice, Ms D saw the nurse with complaints of feeling depressed, frequent stinging during micturition and vulval discomfort. Examination revealed inflammation. An appointment for a cervical smear plus high vaginal swab (HVS) was made and a topical antifungal prescribed.
Speculum examination revealed purulent discharge, which was treated with oral metronidazole. The HVS revealed Candida, G. vaginalis and mixed anaerobes. Ms D was noted as pale and experiencing heavy periods. A vaginal antifungal agent was prescribed. Blood tests showed an iron deficient anaemia.
The patient refused transfusion. On advice from a haematology registrar, ferrous sulphate was prescribed and further tests recommended in three weeks’ time.
After commencing the iron Ms D felt better but was concerned that she might have chlamydia infection. A repeat HVS revealed mixed organisms. Her notes stated ‘no evidence of chlamydia’.
One month later Ms D complained again of vaginal discomfort and discharge. Metronidazole and an anxiolytic were prescribed and hospital referral for haematology and gynaecology consultations proposed. These were deferred for two weeks at the patient’s request.
A month later repeat blood tests were taken. However, further examination was not performed due to vaginal discomfort. Letters of referral to a consultant haematologist and consultant gynaecologist were prepared.
Three weeks later, Ms D was admitted to hospital following a massive vaginal bleed. Ultrasound showed a large mass in the region of the cervix with bilateral hydronephrosis and vesicovaginal fistula. Unfortunately, Ms D died five days later. Postmortem examination confirmed cervical carcinoma.
A claim was made against Dr U and Dr B for alleged failure to investigate why Ms D did not attend appointments, failure to ensure that she had a cervical smear and failure to refer for expert opinion when examination was not possible.
GP experts felt that the GPs had made reasonable efforts to persuade Ms D to attend appointments but should have asked why she consistently failed to do so. Ms D carried some responsibility for failing to have a smear, despite being advised to do so.
The GPs should have referred Ms D to a gynaecologist to investigate the cause of anaemia. Their failure to do so led to a four-month delay in diagnosis of cervical cancer. A gynaecological oncology expert felt the four month delay in diagnosis made little difference to the eventual outcome. If Ms D had undergone a smear during the four years prior to diagnosis, it is likely that the cancer would have been successfully treated with a high prospect of complete cure.
The case was settled out of court for £10,000 plus costs, 50% payable by MPS on behalf of Dr U.
- If a patient does not attend an appointment, this should be highlighted and attempts made to set up another appointment. Efforts should match the severity of the potential pathology and should be documented. Patients should be warned of the potential risks of non-attendance.
- Profound anaemia should be fully investigated promptly regardless of the age of the patient.
- Patients who are depressed may conceal significant signs and symptoms, such as heavy periods.
- Hospital referral for investigation of low haemoglobin, vaginal discomfort and discharge should be made if a GP is unable to fully examine a patient.
- US Preventive Services Task Force, Screening for cervical cancer, www.ncbi.nlm.nih.gov
- Sawaya GF, McConnell KJ, Kulasingam SL, Lawson HW, Kerlikowske K, Melnikow J, et al, Risk of Cervical Cancer Associated with Extending the Interval Between Cervical Cancer Screenings, N Engl J Med: 349:1501–9 (2003)
- Myers ER, McCrory DC, Subramanian S, McCall N, Nanda K, Datta S, et al, Setting the Target for a Better Cervical Screening Test: Characteristics of a Cost-effective Test for Cervical Neoplasia Screening Obstet Gynecol 96: 645–52 (2000)