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Missed early diagnosis of stomach cancer (02HDC08972)

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(02HDC08972, 5 December 2002)

General practitioner ~ Standard of care ~ Appropriate investigations ~ Missed diagnosis of stomach cancer ~ Right 4(1)

A 50-year-old woman complained that her GP did not provide services of an appropriate standard in that: (1) after a normal barium meal investigation the GP did not order any further investigations, although she continued to complain of abdominal pain and vomiting; (2) the GP did not refer her for specialist assessment when her symptoms continued and her general health deteriorated; and (3) the GP did not discuss with her the option of gastroscopy.

Between March 1998 and 2000 the woman consulted her GP on a number of occasions relating to gastrointestinal symptoms. On two occasions, once in 1998 and once in 1999, she was prescribed ranitidine (Zantac) for epigastric discomfit and, in March 2000, omeprazole (Losec) for gastro-oesophageal reflux. In April 2000 the GP referred her for a barium meal investigation, which was normal, and following a positive Helicobacter pylori test started her on a course of clarithromycin (Klacid) to treat her peptic ulcer disease. In March 2002 a low iron level was recorded and the woman started to vomit regularly and violently. A gastroscopy showed a deep stomach ulcer, and biopsies showed this to be an infiltrating carcinoma. At laparoscopy it was found that the patient had a large stomach tumour with associated metastatic disease and ascites. The woman died in July 2002.

The Commissioner reasoned that:

1) stomach cancer is relatively rare in New Zealand, whereas gastrointestinal reflux and peptic ulcer disease are quite common;
2) neither gastroscopy nor barium meal investigations will necessarily provide a definitive diagnosis;
3) although gastroscopy is more accurate, it is a more invasive technique with long waiting times in the public system; and
4) the GP did discuss gastroscopy with the patient in March 2000, as recorded in his notes.

It was held that the GP did not breach the Code, as he had provided services with reasonable care and skill in relation to follow-up of the patient's continuing gastric symptoms and discussions with her about options for investigation.