Mr K was a 36-year-old man who ran a pub. Mr K smoked and drank heavily. Mr K’s dentist had noticed a painless swelling on the right side of his neck during a routine check-up and asked him to see his GP. Mr K was seen by Dr A, one of the GPs at his surgery, who noted that Mr K was unsure how long the lump had been there, and referred him to the ENT outpatient department.
A letter came back to the practice confirming the presence of a lymph node in the anterior triangle of Mr K’s neck, which was felt to be innocuous. The plan was for Mr K to be reviewed in six weeks’ time and for further investigations to be pursued if the node was still present.
Mr K was busy at work and did not feel too concerned about the lump because it was not painful. He did not attend his follow-up appointment and a letter stating this was sent from the hospital to his GP.
Eight months later, Mr K began to get some discomfort in the neck swelling so decided to see his GP again. This time he was seen by Dr B at the surgery. Dr B noted his painful swelling and also a history of chronic tympanic membrane perforations. Dr B did not establish or document his previous referral to the ENT department regarding the same lump or the intended follow up. Dr B’s brief examination notes detailed the tender, swollen lymph node but did not include an examination of the mouth, tongue or throat. Dr B prescribed ibuprofen to help with the discomfort and did not arrange any follow up.
Over a year later, Mr K was still troubled with pain and swelling in his neck. This was getting worse and affecting his mood and sleep so he went back to see Dr B. Dr B did not examine his neck but prescribed some antibiotics, antidepressants and sleeping tablets. He also advised a dental review.
Six months later, Mr K was still struggling with his symptoms and went again to see Dr B. This time Dr B made a referral to head and neck surgery. His referral letter stated “intermittent chronic right sided neck swelling in the preauricular and submandibular area”. There was no mention of any previous referral in his letter. Dr B documented a differential diagnosis of a possible parotid lesion or salivary gland stone.
Mr K’s neck lump subsequently proved to be malignant. As a result he had to have neck surgery and resection of a primary in his tonsil. He had a course of radiotherapy and since has not had recurrence of his disease. Unfortunately he was left with shoulder weakness and a dry mouth, which he found difficult to cope with.
Mr K was angry with Dr B and felt that he caused a delay in his diagnosis. He brought a claim of negligence against Dr B because he felt the delay had necessitated more radical surgery, leaving him with debilitating symptoms.
Expert Opinion
Medical Protection sought the advice of an expert GP (Dr F). Dr F felt that Dr B bore liability for the delayed diagnosis. He was critical of Dr B’s history-taking and recordkeeping. Dr F commented that Dr B had responsibility for establishing the history of his previous referral to the surgical assessment unit. Had Dr B known of that referral, then the duration and the continuing nature of the lymph node would have necessitated immediate re-referral back to that team. Dr F also criticised Dr B’s inadequate examinations, stating that he should have documented an examination of the patient’s neck, mouth, tongue and throat.
The opinion of a professor of otolaryngology (Professor Y) and head and neck surgery was also obtained. Professor Y commented that there was a significant delay between initial presentation and the final treatment. Professor Y thought that an earlier diagnosis may have allowed a less radical neck dissection and it may have been possible to spare the accessory nerve, which controls the muscles of the trapezius and sternocleidomastoid muscle. This would have resulted in less dysfunction to the shoulder and neck.
In addition, Professor Y considered that it may have been possible to spare radiotherapy if he had been treated earlier. The need for radiotherapy in this case was due to the size of the lymph node in the final specimen and the positive margins, which was evident following removal of the tonsil primary.
Due to expert opinion finding Dr B to be in breach of his duty, the claim was settled for a high amount.
Learning points
- Doctors should be familiar with the NICE guidelines (June 2015) for suspected cancer: recognition and referral. In the section on head and neck cancers, the guidelines state that patients should be considered for a suspected cancer pathway referral (for an appointment within two weeks) in people with a persistent and unexplained lump in the neck.
- In the UK the GMC’s Good Medical Practice states that doctors must “adequately assess the patient’s conditions” and “promptly provide or arrange suitable advice, investigation or treatment where necessary”.
- GPs should review patients’ previous records and ask about previous relevant history when consulting.