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Late diagnosis of abdominal tumour and DVT (04HDC14223)

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(04HDC14223, 24 May 2005)

General practitioner ~ Back pain ~ Cancer ~ Differential diagnosis ~ Atypical presentation ~ Investigations ~ Examinations ~ Referral ~ Right 4(1)

A 71-year-old woman went to her general practitioner (GP) with severe pain in the back of her upper right leg, from no apparent cause. The GP's efforts to control the pain were ineffective, and three weeks later she was admitted to hospital, where deep vein thrombosis (DVT) and mantle cell lymphoma were diagnosed. The woman died six weeks later. The woman's daughter complained that the GP's assessment, investigation and treatment of the leg pain were inappropriate.

At the first consultation the GP diagnosed sciatic nerve pain, and prescribed pain relief and an anti-inflammatory. Ten days later, the woman saw her GP again as there was no relief. The doctor reassessed her and recommended X-rays of the lumbar spine and right hip. The woman chose to have the X-rays taken at the public hospital, rather than privately, even though this led to a delay of some weeks.

A fortnight later, still in a lot of pain, the woman returned to the GP, accompanied by her daughter. She had not yet been given an appointment for the X-rays, and she asked whether ACC would cover private treatment. She recalled that she had lifted a heavy pot the week before the pain started, which could be the cause and would qualify her for ACC. The GP completed an ACC claim form. The X-rays were taken that day. The GP received the X-ray report the next afternoon (a Friday). The report indicated no spinal or hip abnormalities, and the doctor intended following up with the woman the coming week. However, that weekend, the woman went to the public hospital with a swollen leg. The doctor there suspected DVT and ordered an ultrasound. The radiologist, concerned by his abdominal examination of the woman, extended the ultrasound to the abdomen. The ultrasound revealed a large abdominal tumour and a clot extending from the mid-femoral artery up into her abdomen. The DVT was probably a later consequence of the tumour. The late-stage tumour did not respond to treatment and the woman died.

Back pain and nerve root irritation are extremely common presentations in general practice. The vast majority are due to straightforward mechanical low-back pain and respond to the treatment the GP instituted at the first visit. He arranged for the woman to return if treatment proved ineffective. This action was held to be appropriate and not a breach of the Code.

It was held that the GP breached Right 4(1) in the latter two consultations by not instituting further tests and examinations earlier, and by not expediting the X-rays.