Poor examination of breast skin causes complaint

We help Dr B through an NHS England investigation, following a complaint over his breast examination. By Dr Emma Green, Medicolegal Consultant, Medical Protection. 

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 breast.

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.

How did Medical Protection assist?

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 team.

Outcome

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 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.

Learning points

It is important to ensure that deskilling or limited exposure to common conditions does not result from how patients are allocated to clinicians or unfounded preconceptions.

Suggesting a workable development plan to show evidence of learning may be required where reflections are not enough. This may include audit or targeted consultations.

Medical Protection can support doctors through local NHSE processes, which can be stressful and may include meetings with clinical advisers.

In this case the NICE guidelines suggested that referral should be considered; however, local guidance had skin dimpling as a reason for referral. Clinicians should be able to justify referral decisions, taking into account both local and national guidance; however, safety netting or review is also important where decisions are not clear cut.