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Missed diagnosis of ovarian cancer (01HDC00389)

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01HDC00389, 31 October 2002)

General practitioner ~ Standard of care ~ Missed diagnosis of ovarian cancer and ascites ~ Clinical examination ~ Record-keeping ~ Rights 4(1), 4(2)

A woman complained that her general practitioner did not adequately examine her, did not diagnose ascites, and did not refer her for further tests or assessment.

The 48-year-old woman had visited the GP for her annual vaginal smear. The GP did not examine her abdomen for lumps. Two months later the patient returned after noticing a lump in her abdomen, and for a prescription to treat recurrence of her reflux oesophagitis. The GP informed her that the lump, viewed while standing, was an epidermal cyst adjacent to an abdominal scar, and recommended an ultrasound. The patient said she would arrange this herself, but the ultrasound was not performed, as the patient was immobilised by a fall. One month later the patient returned with a distended abdomen and breathlessness. On the basis of the patient's normal PRFR (a measure of lung function) and examination findings, the GP diagnosed asthma and prescribed a short course of prednisone.

Ten days later the patient returned with an uncomfortable, bloated abdomen and discomfort in her thigh. The GP attributed the discomfort to the earlier fall and attributed the recorded weight gain to being immobilised and a side effect of the prednisone. He did not examine her abdomen. The patient consulted another GP, who referred her for an abdominal ultrasound, which revealed ovarian cancer.

The Commissioner reasoned that:

1) if the GP had examined the patient's abdomen in her later presentations to him, he would have found either ascites or the pelvic masses;
2) the NZMA Code of Ethics (1989) requires that individual doctors "ensure that every patient receives a complete and thorough examination into their complaint or condition" and that "accurate records of fact are kept";
3) it is important for a doctor to establish a patient's "agenda", ie, the list of complaints and expectations of the consultation - the patient's symptoms of abdominal bloating were not adequately explored;
4) pelvic examination is particularly poor in screening for ovarian cancer and is not indicated as part of a routine smear; and
5) diagnosis of ascites is not easy, especially if it is early or mild.

It was held that the GP:

1) breached Rights 4(1) and 4(2) in that he failed to perform an abdominal examination when the patient complained of a lump in the region of an abdominal scar, and failed to follow up a referral for an ultrasound examination; and
2) did not breach Rights 4(1) and 4(2) in his failure to diagnose ascites.