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Dr B, a GP, contacted Medical Protection for advice
following receipt of a complaint sent to NHS England (NHSE). He had seen a
63-year-old patient, Ms X, who had reported some discomfort in her left breast.
The patient reported no lump or skin changes. Dr B had examined Ms X and found
no lump; however, he noticed an area of skin that he described as “dimpled”.
When examining the patient this area of skin dimpling resolved on elevating the
Dr B also examined the axilla and felt they were clear.
Given that the dimpling appeared positional, Dr B felt that
the patient had no red flags and there was no requirement for referral under
the two-week wait rule. He advised the patient to take evening primrose oil but
did not arrange any further follow up despite the patient being concerned about
the skin finding.
Three months later the practice received a
complaint, which had been sent directly to NHS England. The patient had made
the complaint following a breast cancer diagnosis, which had been made after the
patient had requested a referral from another GP at the surgery. NHS England
undertook a clinical review, which highlighted that the patient management was
not in accordance with local guidelines and requested reflections from Dr B.
Medical Protection reviewed Dr B’s reflections and made
suggestions to focus the reflections on the area of concern. The concern from
the patient focused mainly on the fact that they were told later that the skin
changes should have been referred, but also Dr B commenting during the consult
that he rarely saw female patients with breast problems as he preferred his
female colleagues to see them.
Dr B was asked to attend an initial meeting with a clinical
adviser who felt that although the reflections showed some evidence of
paper-based learning, there was not sufficient evidence to reassure them that
Dr B was seeing enough patients with breast problems. The adviser also felt
that breast elevation as documented in the records would not form part of the
expected breast examination despite a standard examination being described as
part of reflective practice.
Dr B and his Medical Protection adviser had
discussed prior to the meeting that his lack of exposure to patients with
breast problems may potentially be a problem, due to how the practice triaged
patients to female doctors as a matter of routine. Dr B could not recall seeing
a patient with a breast problem for a long time but felt the practice
population and his colleagues would be amenable to arranging for him to see
patients attending with breast problems. Dr B and the NHSE adviser agreed that
he would submit further reflections in two months following a period of seeing
increased numbers of breast patients for review by the professional standards
Over the following six weeks Dr B was able to see 15
patients with breast problems and he submitted further reflections to NHSE on
the experience and how he had managed the range of complaints that had
presented. A colleague at the practice also observed some consultations for
peer review of examination technique in a chaperone role.
Dr B had seen at least two further patients with skin
changes, both of whom were diagnosed with breast cancer, which allowed
reflections on the impact on Ms X. Dr B also reflected on his preconception
that most female patients with breast concerns wanted to see a female doctor.
All the patients he had seen during the period had explained they would rather
be seen sooner than wait to see a female doctor.
Following the submission of further reflections and
the in-depth review of the 15 consultations of breast patients, the
professional standards triage team closed the case with no further action. They
said they felt fully reassured that all concerns had been addressed.