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Inadequate follow-up of test results in patient with malignant lymph node (02HDC13523)

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(02HDC13523, 4 February 2004)

General practitioner ~ Follow-up procedures ~ Reporting of test results ~ Communication ~ Referral ~ Rights 4(1), 4(4)

A man and his wife complained about the services provided by two GPs. The 52-year-old patient presented to the first GP with an asymptomatic lump on the right side of his neck. The GP mentioned the likelihood of malignancy and ordered blood tests to exclude other pathology before a possible ENT referral. He advised the patient to telephone him for the results.

When the patient phoned he spoke to a practice nurse, who correctly advised him that his results were normal. The patient saw no reason to talk to the GP directly, as he assumed that there was no reason for undue concern, as his results were normal. The GP was not informed of the conversation with the nurse. As the results were normal and he had not been phoned by the patient, he assumed that the problem had settled and thus no follow-up was instituted.

Four months later the patient presented to another GP at the practice, as the lump was increasing in size. The second GP recommended removal of the lump and advised that he was able to perform the surgery. He told the patient that his notes indicated that the first GP had referred him to an ENT specialist, and he was probably still on the waiting list. The patient elected to have the surgery performed by the GP rather than wait. At no time did the two GPs discuss the case.

The following week the second GP performed an excisional biopsy, during which the patient noted that there was a lot of blood and the GP "cut and thrust and pulled" for about 20 minutes. The GP abandoned the procedure when he realised that the lymph nodes were too deep. He arranged for referral to a private general surgeon, and further surgery confirmed a diagnosis of cancer.

The first doctor was found in breach of Right 4(4) of the Code. The Commissioner was critical of the system for managing patient test results and the failure to follow up as planned, and stated: "The potential cancer diagnosis for [the patient] required proactive follow-up. In my view, it was incumbent upon [the GP] to ensure that he discussed next steps (such as specialist referral) following the negative blood test results, and that appropriate action followed."

The second GP was found in breach of Right 4(1) of the Code with regard to his decision to perform the excisional biopsy. The Commissioner noted that normal practice is initially to perform a fine needle aspiration in such cases.

Furthermore, the GP was unwise to perform the operation without sufficient experience, training or facilities to deal with such a procedure. Damage to the patient's parotid gland, which required removal by the general surgeon, was also found to be "an adverse event attributable to [the second GP's] inappropriate decision to attempt excisional biopsy".

This case highlights the need for efficient systems for handling test results and referrals, particularly in cases where the diagnosis may be severe. It also illustrates that GPs must be aware of their limitations and the need to err on the side of caution when considering whether to refer a patient for specialist care.