GP's failure to examine a patient delayed cancer diagnosis

What happened

Mrs A said her GP did not examine her during the three consultations and she thought he should have done so at least during the last two.

Mrs A was dissatisfied with her care and joined a different practice in late 2013. Her new GP carried out an internal examination and found a lump. He urgently referred Mrs A to hospital for further investigations for a suspected cancer of the womb.

Doctors diagnosed a rare cancer and Mrs A had surgery to remove it. Sadly, the cancer returned within a matter of weeks and she died in the summer of 2014.

What we found

The first GP did not examine Mrs A when he should have done. The care and treatment provided by the GP fell so far below applicable standards and established good practice that it was service failure.

We could not find that Mrs A would have survived had the GP examined her when he should have done, but it might have improved her chance of survival. The failings in Mrs A's care caused deep distress to her and her husband and this was an injustice to them. In addition, Mr A will never know if his wife's life could have been prolonged or saved but for the failings in her care. This is an additional injustice to him.

Putting it right

The Practice wrote to Mr A to acknowledge the service failure and the impact that had on Mr and Mrs A. It also paid £1,000 to Mr A in recognition of the injustice caused to him.

We noted that following its own review of its actions in Mrs A's case, the Practice's GPs developed their knowledge of the symptoms of this rare cancer and its management. In addition, the GP reviewed and changed his own practice in order to avoid a recurrence of the failings we identified.