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Missed diagnosis of advanced colorectal cancer (10HDC00253)
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(10HDC00253, 15 October
General practitioner ~ Standard of care ~ Colorectal cancer
~ Missed diagnosis ~ Documentation ~ Hot key function ~ Rights
4(1), 4(2), 4(4)
A 66-year-old woman complained about the care provided to her by
a GP who failed to diagnose her colorectal cancer.
Between November 2007 and November 2008 the woman consulted the
GP on a number of occasions complaining of tiredness and shortness
of breath. The GP diagnosed her with iron deficiency anaemia and
prescribed iron supplements. Her iron levels initially improved but
dropped again, and the GP prescribed more iron supplements. Her
health did not improve. On two occasions in 2008, after presenting
with vague upper abdominal symptoms, the GP diagnosed the woman
with gastritis without carrying out any abdominal examination.
In November 2008 the woman sought a second opinion from another
GP, who immediately identified a swollen liver. Following blood
tests and a CT scan, the woman was diagnosed with advanced
It was held that the GP breached Rights 4(1) and 4(4) for
failing to appropriately investigate and manage the woman's iron
deficiency anaemia, and failing to examine the woman's abdomen
prior to diagnosing gastritis.
The GP was also found in breach of Right 4(2) for failing to
meet professional standards in terms of his documentation, by
failing to accurately record examination findings and the activity
that took place during some consultations. When recording the
notes, the GP used the "hot key" function, which enables a word,
phrase or list to be inserted quickly, but had not carried out the
examinations as recorded.
The Commissioner recommended that the Medical Council consider
whether a review of the GP's competence was warranted. The GP was
referred to the Director of Proceedings. The Director decided to
issue proceedings, which are pending.