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Decision report 201004844

  • Case ref:
  • Date:
    September 2011
  • Body:
    A Medical Practice, Grampian NHS Board
  • Sector:
  • Outcome:
    Upheld, recommendations
  • Subject:
    clinical treatment / diagnosis

In August 2009 Mrs C attended her GP complaining of a lump in her left breast. She was examined and asked to return for a follow up appointment a week later. She was seen by a different GP at the review appointment and was advised that the lump was most likely a cyst. She was told to monitor the lump over the course of a few menstrual cycles. No follow-up appointment was made. Mrs C said that the lump increased in size and she returned to her GP practice in August 2010. She was seen by a third GP, who was concerned by the lump and referred her to a breast clinic for further investigation. The lump was found to be cancerous. Each of the three GPs described the lump as being in a different location and the Practice concluded that different lumps had been examined.

Mrs C maintained that she had had the same lump since August 2009 and that it had increased in size. She complained that the first GP incorrectly noted the lump as being in her right breast, and that she should have been referred to the breast clinic by the second GP. Although it was not possible for us to confirm whether there had been three different lumps, or if the same lump had been described differently, we upheld both of Mrs C's complaints, as we found the first GP's record-keeping to be poor and possibly inaccurate. We found that the treatment plan proposed by the second GP was not in line with good practice guidance and that Mrs C could have been referred to the breast clinic significantly earlier, or had it confirmed whether her lump was just a cyst.

We recommend that the practice:
• add a note to Mrs C's records clarifying that she attended her examination on 14 August 2009 complaining of a lump in her left breast;
• draw their staff's attention to the guidance in SIGN 84 and the Scottish Primary Care Cancer Group's publication: Scottish referral guidelines for suspected cancer; and
• apologise to Mrs C for the failings identified by our investigation.

 When this report was first published on 21 September 2011, it was incorrectly categorised as being about Greater and Glasgow and Clyde NHS Board. This was due to an administrative error which we discovered on 22 September 2011, and for which we apologise.


Updated: March 13, 2018