Mrs B died in 2018 of complications from her carcinoma of the bowel which was first identified during a digital examination in the same year. She was in her thirties and her death was a tragic loss at such an early age.
Her story is recounted in a 34-page document released by the Health and Disability Commissioner (HDC) where the family doctor (Dr A) was found in breach. The Commissioner amongst other things stated:
“Dr A had a responsibility to provide services to Mrs B with reasonable care and skill and, in my opinion, did not discharge that responsibility. There were missed opportunities to refer Mrs B for a lower GI endoscopy, and this led to a delay in Mrs B receiving a diagnosis and treatment for bowel cancer. In March 2016, Dr A should have recognised the unexplained iron deficiency and referred Mrs B for endoscopy.”
While all that sounds quite cut and dried, the realities of the case were much more complicated.
Mrs B had been a patient of Dr A since 2012 and was well known to the practice due to her complex medical history, including severe asthma (with a history of steroid dependency which when corrected resulted in her losing between 25 and 35 kilos), osteoporosis, allergies, hidradenitis suppurativa (requiring surgery), anxiety, depression, blood clots in the veins, essential thrombo-cythaemia (for which she had regular blood tests including for her iron levels), mechanical back pain (requiring surgery), and haemorrhoids. She also had a history of personal trauma. In 2007, Mrs B had an incision and drainage of a perianal abscess and in 2013 was treated for a blood clot in a haemorrhoidal vein. She had a history of irregular bowels and bleeding, “since the birth of her last child.”)
In addition to frequent GP visits, between 2015 and 2017 Mrs B had ongoing reviews by rheumatology, dermatology, respiratory, and haematology clinicians, including three to four monthly blood tests to monitor her platelet count. Although not specifically stated, she must have also had surgery for her skin condition and her back injury. She also has a recorded digital rectal examination by another doctor in the medical centre in 2015. Notwithstanding this, there were several reports of irregular bowel habits and bleeding.
She was referred to the gastroenterology department on two occasions. Firstly, by the haematology department (in June 2016) and then by the rheumatology department (in July 2016), but both were refused as they did not fit the referral criteria. It is likely that the GP saw those refusals but might not have been aware of the nature of the referral letters.
It is easy to opine, but more difficult to give answers. However, my first observation is that there were a lot of subspecialists involved, but currently it is the role of the general practitioner to take on the role of “the generalist looking at the big picture” rather than just battling the acute issues that arise. An extended consultation to review this case would have been ideal. (Dr A did arrange bloods and stool samples and request a full follow-up but the patient defaulted, and he was criticised for not following that up).
Finally, the Commissioner directed that Dr A watch a 2017 presentation from The Royal Australasian College of Physicians (RACP) titled “Cognitive bias and diagnosis.” Although it is presented by a secondary care physician it relates very well to primary care and is recommended watching for all primary care doctors. Watch the video.