NHS Resolution have published the findings of their recent review of successful GP negligence claims involving delays in diagnosis of a patient’s cancer. Their report, ‘Delayed diagnosis of cancer: a thematic review of general practice indemnity claims’, reveals the mistakes, miscommunications, administrative errors and resulting delays which deprived 105 patients of their opportunity to have their cancer diagnosed at an earlier, more treatable stage. NHS Resolution emphasise that these cases must be viewed in the light of the one million GP patient consultations and 950 new cancer diagnoses which take place each day. However, they also acknowledge that claims data doesn’t capture all instances of delayed diagnosis, and that the delays in these cases were not the result of difficulties in accessing a GP appointment, but arose from the content of GP-patient consultations, the advice given and action taken, and the patient’s inability to access specialist cancer services without a GP’s urgent suspected cancer referral. GP gatekeepers are ‘potential bottleneck’ for timely cancer referrals According to NHS Resolution, data indicates that cancer survival in the UK is currently at its highest but the UK still falls behind many westernised countries for early diagnosis, cancer morbidity and mortality. Improving earlier detection of cancer to provide earlier treatment and better outcomes for patients is a key national health policy. In addition to raising awareness of cancer and the importance of screening, timely diagnosis and treatment relies on successful navigation of cancer pathways through the healthcare system and input from healthcare staff, including pathologists, radiologists, specialists, pharmacists, emergency care teams, as well as general practitioners (GPs). Whilst the patient’s eventual treatment and outcome can be affected by delays at any point in their care, the review emphasises that GPs play a vital role in their patients’ diagnosis and treatment as gatekeepers of access to specialist diagnostic imaging and specialty cancer services, and are a ‘potential bottleneck’ for timely referral for suspected cancer. Early detection of cancer is recognised as the most effective way to improve cancer outcomes and the cancer’s stage at diagnosis often predicts the patient’s chances of survival. If cancer is allowed to progress untreated, it grows from Stage 1 and 2 (where it is localised to its site of origin) to invade nearby tissues, muscles and organs by Stage 3, and spreads to form new tumours in more distant areas of the body (metastases) by Stage 4. Even short delays in diagnosis can significantly reduce the treatability of the patient’s cancer, their treatment options and their prognosis. What GP mistakes lead to delays in diagnosis of cancer? NHS Resolution reviewed 105 successful medical negligence claims against GPs involving the delayed diagnosis of cancer. The injured claimants had an age range of 18 to 84 years. Nearly a third (32.3%) were under 50 and nearly three quarters (73.5%) of those whose (early onset) cancer was diagnosed before they were 50 were female. The total compensation (excluding legal costs) paid to the 105 patients or bereaved families was £2,187,821. Nearly all (97%) involved care which began before the Covid-19 pandemic’s first wave in March 2020. Nearly a quarter (24.8%) of the GP negligence claims involved additional negligent delays in the patient’s secondary (i.e. hospital) care. The most common cancers featured in these claims were colorectal, skin, breast and urological/prostate cancers. The three most commonly diagnosed cancers in England are prostate, colorectal and breast cancer, and these accounted for the cases with the highest total costs ( combined compensation and legal costs) in the review. The longest delays between the patients’ signs and history mandating (under NICE guidelines) an urgent cancer referral and actual referral were for prostate cancer (16 months), skin cancer (14 months) and gynaecological cancer (12 months). Failing to make or review a diagnosis None of the patients in the reviewed claims received a two week wait (2WW) urgent referral at their first appointment with their GP. NHS Resolution point out that this could be explained by the need to first obtain diagnostic tests to support a diagnosis or to observe and review the patient’s response to initial treatment where the diagnosis isn’t immediately obvious. However, they found that the content of the first GP appointment and initial diagnosis affected the patient’s safety-netting and the doctor’s assumptions at each subsequent visit, which often continued the initial plan or course of treatment based on the first visit or initial diagnosis, without considering whether that diagnosis could be wrong. There was a lack of differential diagnosis in the majority of claims. In many cases there were no safety-net instructions or follow-up arrangements to monitor the original diagnosis or the patient’s response to an initial trial of treatment. In some cases, symptoms were treated without any diagnosis at all, and diagnostic mistakes were then compounded by diagnostic overshadowing, in which new symptoms were incorrectly assumed to relate to a patient’s co-existing condition. In many cases, clinical symptoms that persisted after negative or normal diagnostic test results were not further investigated or referred, even when the patient repeatedly came back to the GP with the same or evolving symptoms. Instead of reviewing the initial diagnosis, GPs treated the patient for benign conditions with multiple trials of alternative or escalating treatments, such as antibiotics, painkillers and inhalers. Reassurance was often given as a ‘treatment’ alongside these medications, and patients who asked about cancer were told that cancer was unlikely owing to their age or lack of risk factors, despite national concerns about the rise in early-onset cancer. Many patients with undiagnosed cancer who were falsely reassured delayed seeking further medical help for their worrying symptoms. Failing to take a proper history The review found that insufficient history-taking featured in most claims, with the GP noting limited details about the progression, change or impact of symptoms, the patient’s eating and bowel habits, or the patient’s risk factors which in 10.5% of cases included a prior history of cancer. The records often lacked evidence of planned investigations, safety-netting and follow-up instructions. The significance of weight-loss and reduced BMI was not recognised, and these signs were not consistently monitored. Failure to escalate or act on persisting symptoms or abnormal results Where patients were referred for diagnostic investigations or speciality assessment, these referrals were made routinely and were not expedited or updated when the patient came back to the GP with deterioration or new symptoms. New abnormal findings did not result in escalation to senior staff members, repeat investigations, follow-up appointments or urgent referral to specialists. The review found that failure to act on abnormal results was a common theme. The significance of elevated diagnostic pathology results often wasn’t mentioned to patients and follow-up or repeat tests were not initiated by the GP practice. In claims where patients were under the care of several hospital specialties and received abnormal results, the requesting outpatient specialty neither took ownership of the necessary follow up, nor highlighted to the GP the abnormal results and the need for referrals, repeat abnormal blood tests or follow up with the patient. Recommendations or abnormalities which were highlighted by radiology were often not followed up by the GP with any urgency. Lack of urgency and delays in referrals In cases where diagnostic tests and imaging were ordered routinely, they could take up to six weeks to be performed. Where diagnostic tests were ordered urgently, follow-up appointments were often booked up to six weeks later. Patients sometimes secured earlier appointments through their own efforts or by opting to pay for tests (such as chest x-rays) to be carried out privately. GP surgery requests to the patient to arrange a post-result appointment with their GP were often issued without the patient being advised of the significance of the tests or the need to attend the GP urgently. Referrals were then delayed until the patient communicated with the GP. Patients who cancelled specialist appointments were later assumed by the GP to have been seen by the specialist team. In some cases, the review found that despite an intention to make an urgent referral for suspected cancer, digital or administrative errors left the urgent referral unmade or converted to routine when it was processed by the administrative team. In some cases, referrals remained unprocessed for several months. In other cases, decisions were overridden, such as scheduled requests for appointments for repeat monitoring of a patient’s smear tests being overridden when the patient was outside the standard age for screening, or where GPs cancelled their colleagues’ requests for referrals or x-rays which they deemed unnecessary. NHS Resolution found that whilst NICE guidance exists to support doctors with making referral decisions, their review found evidence of non-adherence to NICE guidance across claims in all cancer subspecialties. The impact of delayed cancer diagnosis on the patient NHS Resolution’s review of delayed cancer diagnosis in GP negligence claims highlighted patients’ dependence on their GP for access to diagnostic testing and referral for specialist care. The patients in the reviewed, successful claims felt that they had not been listened to by their general practice staff, and that their concerns were minimised or dismissed. Many had needed family members to advocate for them or had sought private diagnostic testing to overcome the barriers they had experienced during their GP care. Patients had sought help from NHS 111, the ambulance service, out-of-hours centres and emergency departments, but those who persisted in only attending their GP suffered some of the longest delays. Patients with less common cancers attended an average of 15.5 healthcare visits before receiving their cancer diagnosis, with the median (average) of 7.4 visits across all types of cancer claims. All the claimants in this review visited their GP three or more times before referral and diagnosis, which NHS Resolution quotes as the research-based standard definition for an avoidable delay. Nearly two thirds (65.7%) of the patients in the reviewed claims had Stage 3 or 4 cancer at diagnosis, with many having received multiple courses of antibiotics and other treatments despite negative findings and non-response to treatment. More than half (53.3%) already had cancer in their lymph nodes and almost a third (30.4% ) had metastatic cancer by the time they were diagnosed. In many claims, these patients had already died and their claims were pursued by their families. The delay in diagnosis was reported by patients and their bereaved families to have caused long periods of avoidable pain and distress, increased surgery and scarring, whilst reducing their treatment options, increasing their risk of cancer recurrence and shortening their life expectancy, and reducing their quality of life. If you have suffered severe injury as a result of medical negligence or have been contacted by HSSIB, MNSI or NHS Resolution, you can talk to a solicitor, free and confidentially, for advice about how to respond or make a claim by contacting us.
