HDC case - oesophageal cancer

By Dr Peter Moodie, College Clinical Advisor

27 October 2023

Category: Clinical


The Case

On 10 December 2020, Mrs A visited her usual practice with symptoms such as fatigue, loss of appetite, a 7 kg weight loss over the last two months (she weighed about 40 kg), feeling of cold, tingling limbs, reddened palms and poorly fitting dentures which affected chewing. Mrs A was in her 60s and had a history of high blood pressure and SLE. She was an alcoholic and had been drinking two 鈥渟tubbies鈥 and a bottle of wine per day for some years, and she had also been a heavy smoker too.

Mrs A had been brought in by her husband, and although she had been a member of the practice for some years, she had not had regular contact with the practice for five years and indeed her last appointment was three years before then.

The circumstances

On this occasion Mrs A was seen by a short-term experienced locum Dr C who was employed for one to three short afternoon sessions per week and left the practice shortly after, in January 2021. Although Dr C worked part-time, she had no remote access to the practice, nor was she able to access the practice after hours. Furthermore, on the day of the consultation, computer and printing problems meant that she had had to retype several of her case notes from memory and make some of her referrals by fax.

Dr C attributed Mrs A鈥檚 condition to her alcohol consumption. On examination, she identified an abnormal probably cirrhotic liver, and in addition to blood tests she also ordered an ultrasound of her abdomen. Presumably because of the computer problems, she printed out the ultrasound request and asked practice staff to fax this through to the hospital. The consultation was thorough, as she also identified that Mrs A was due for a mammogram, and this was successfully ordered electronically.

Although her notes were subsequently criticised for brevity, they weren鈥檛 that brief (pages 20/21 HDC report 20HDC02065). Dr C argued that they had almost certainly been retyped and could be well understood by others.

The HDC quoted a Medical Council edict that stated that 鈥渁dded or amended notes should be signed and dated along with the reason for any changes鈥. This direction had plainly been written before the advent of computers.

On 17 December, Dr C reviewed the case and resent the fax for the ultrasound, in case it had not been received by the hospital. She also rang Mrs A about her blood results; however, the HDC noted that the phone call did not include details of what was said.

The ultrasound prioritisation

On 19 December, a radiologist responded to the ultrasound request with an electronic letter and a hard copy, explaining that they had assigned it a category C priority, which meant there would be a delay of up to 38 weeks. There was an invitation to supply more information, if Dr C did not agree with these time frames.

Unfortunately, the hospital sent the information to the wrong practice. Somehow (not explained) a hard copy did reach the correct practice on 23 December, but Dr C is adamant that she did not see it and said that for the previous 30 years she had always signed any hard copy as proof that she had seen it and if she had, she would have rung the radiology department. The practice indeed had a curious method of managing hard copy documents: when received, the letter would be scanned into the computer, the hard copy would be then given to the relevant doctor who reviewed it, annotated it and then gave it back to reception. The letter was then given to another doctor (Dr E) who filed it electronically and the original document was then destroyed.

The practice argued that Dr C must have seen it, but the HDC identified that there was no proof that she actually did.

Dr Peter Moodie

The practice audit log showed that the hard copy letter was scanned on 23 December and that it was finally filed by Dr E on 28 December. The practice argued that Dr C must have seen it, but the HDC identified that there was no proof that she actually did. As the letter was scanned before it was reviewed, it couldn鈥檛 have any added comments on it. Dr C finished at the practice in mid-January. Although there were some minor criticisms, her actions were considered to have been reasonable.

Another examination

On 31 December 2020, Mrs A was again brought into the practice and seen by Dr B, as her condition was deteriorating. Dr B noted that there had been episodes of melaena, but her bowel motions were now brown. He had read Dr C鈥檚 notes and, since she had been examined by Dr C three weeks before, he didn鈥檛 palpate her abdomen, as he felt there was nothing to be gained. His provisional diagnosis was of GORD, and he prescribed omeprazole along with an action plan to review her in four weeks.

He did however record a differential diagnosis of a possible carcinoma (pages 20/21 of the HDC report). He said that he had wanted to admit Mrs A that day, but Mrs A declined as this was on New Year鈥檚 Eve Unfortunately, he did not record this in the notes, and Mr A later denied that he had suggested that.

Dr B was criticised for not examining the patient, not recording her haemodynamic status, not organising bloods, and not recording the patient鈥檚 refusal of admission.

Emergency department

Five days later Mrs A went to an emergency department and was diagnosed with a carcinoma of the oesophagus with both lung and liver metastases. We can assume that the proposed 38-week delay in imaging was not implemented. Mrs A died 3 weeks later.


Mrs鈥 A fate was sealed well before her consultation on 10 December, and it is unlikely that any earlier intervention on either 10 or 31 December would have made any difference. If, however, Dr B or Dr C had had easier access to imaging tools, the diagnosis could have been made earlier.

It is surprising that there was no criticism of the hospital for sending a report to the wrong practice, as this might well have resulted in an earlier diagnosis. Indeed, this is the second case in recent times where hospital communications have been found wanting.

It is also surprising that a referral for ultrasound in a patient with probable cirrhosis was given such a low priority. Even without it being stated on the referral form, the possibility of malignancy should have been considered.


  • Invariably, your case notes will be examined in great detail by the HDC. In this case, the hospital notes 鈥 possibly with the benefit of hindsight 鈥 referred to her having 鈥渄ysphagia over several weeks鈥. [PM1] Dr C who saw Mrs A first, stated that there was no suggestion of dysphagia, and if there had been, she would have regarded this as a red flag. Dr D considered GORD as a differential diagnosis and again made no mention of dysphagia. No mention of this symptom was carefully considered by the HDC.
  • If a patient declines to accept your advice, you need to document that very clearly.
  • In this case the practice had some poor management processes. Other peoples鈥 processes can get you into trouble.

Finally, if you do read the original HDC report (20HDC02065) you may find yourself confused by the dating system used. The first time that Dr C saw the patient is recorded as 鈥10 Month 1鈥, which you might interpret as January 10, but this is not the case. It refers to the 10th day of the first month of the case. The system is flawed from a number of positions: firstly, Month 2 in this case should not start until the 10th of the following month, otherwise the case appears to have dragged on longer than it actually did. Secondly, the dating system should actually start at 鈥淢onth 0鈥). The dating system is reputedly used 鈥渢o protect privacy鈥. However, at various points in the report the true dates are obvious. So much for privacy!

This article was originally published in the October issue of "GP Voice"