Clinical Risk Management Assignment: Ms. Moulder Case Study on Delayed Breast Cancer Diagnosis and Care Gaps

Case Study

Ms. Moulder is a 30-year-old patient who is under the care of; • Dr Skinner, General Practitioner and, • Mr Scully, Consultant Surgeon specialising in breast surgery. Ms. Moulder is worried about a lump in her right breast and sees her GP, Dr Skinner, on 15 October 2022. Her GP carries out a physical examination. She is not too worried but tells Ms. Moulder that, for assurance, she would prefer to refer her to a specialist and writes a letter of referral to Mr. Scully, which states: 15/10/2022

Dear Mr. Scully, I would appreciate it if you would see this patient. She is worried about a lump in her right breast. She has no notable history. Possible that her mother had breast cancer, details not known. Patient is otherwise healthy. I have examined her and am not particularly worried , but I would appreciate if you would see her all the same, which may reassure her. Yours, W Skinner.

Mr. Scully’s clinic received the letter on 27 October 2022, and the secretary called Ms. Moulder to arrange an appointment. However, there is no one at home, and the secretary leaves a message requesting that Ms. Moulder call the clinic. On 14 December, Ms. Moulder returned to her GP complaining of discomfort in her breast. The GP enquired what had taken place with Mr. Scully, and the patient told the GP that she had been waiting for an appointment but had heard nothing. The GP again examined the patient and thought that there had been no change and said that she would again contact Mr. Scully to arrange an appointment.

The GP wrote another letter that referred to the previous letter of referral. Further, the GP stated that the patient had been in again, complaining of discomfort. The letter stated that the GP did not think there had been any change and could Mr. Scully arrange to see Ms. Moulder. This second referral letter was sent on 23 December 2022.

Ms. Moulder received a letter from Mr. Scully’s clinic asking that she call the clinic to arrange an appointment. This letter was received on 15 January 2023, but Ms. Moulder was out of the country. On her return on 30 January 2023, she made contact with the clinic, and an appointment was arranged for 7 February 2023.

On 7 February 2023, the patient met with Mr. Scully. He stated that he had received a letter from her GP in December 2022 and wanted to check to make sure that “everything is in order”. He tells her that he needs to examine her breasts. She tells him that the discomfort was in her right breast, and she thinks it seems to have settled. Mr. Scully carries out a physical examination of her breasts. He seems reassured and tells her that he does not think it is anything to worry about and that he thinks this is simply a benign fibroadenoma (non-cancerous lump). He also tells her that he would like her to undergo an ultrasound scan and that he would like to carry out a biopsy as part of a “triple assessment” (which consists of a physical examination, a scan, and a biopsy). He tells her that on her way out, she can arrange a further appointment with his secretary or call her at any stage to arrange this.

Ms. Moulder is delighted with the reassurance she receives from Mr. Scully. She told his secretary that she was very happy and reassured. They discussed a few dates which did not suit the patient. Ms. Moulder told the secretary that she would be away for three weeks but that when she gets home today, she will check her diary and she will call the clinic to arrange an appointment. Nothing further occurs. The patient did not call the surgery to make a further appointment.

On 20 October 2023, Ms. Moulder re-attended her GP with pain and discomfort in her right breast, which had been worsening over the last month. The GP again enquired what took place since her appointment with Mr. Scully. She told him that she felt reassured by Mr. Scully and was of the understanding that she would receive a letter for a further appointment. She also told her GP that she is now 8 weeks pregnant. The GP immediately called Mr. Scully’s clinic to arrange an urgent appointment.

On 25 October 2023, the patient received a letter asking her to attend on 30 October 2023. She attended the hospital, where an ultrasound scan and a biopsy were carried out.

She did not meet with Mr. Scully on this occasion and was told that she would be contacted by her GP.

On 20 November 2023, her GP called Ms. Moulder and asked her to attend her surgery. Unfortunately, the test results have indicated signs of a cancerous growth in her right breast and further tests will be required to diagnose the extent of the problem. Dr Skinner tells the patient that she should contact Mr. Scully’s clinic to arrange a consultation. The patient is understandably very upset with this news. She has also been dealing with early sickness in pregnancy and eventually gets around to making an appointment on 5 December 2023.

A further appointment is made for 20 December 2023, and after further tests were carried out, it transpires that the patient is unfortunately suffering from breast cancer, which seems to have metastasised (spread to other parts of the body). The patient will unfortunately require extensive treatment, including surgery and all of this may have implications for her pregnancy. She does not understand how this could have been allowed to occur in circumstances when she first attended her GP over a year before in October 2022. She is very angry with her GP and with Mr. Scully and wants answers. She, therefore, goes to consult a solicitor.

You are a recent graduate of the Graduate Diploma in Health Care (Risk Management and Quality) and the newly appointed member of the clinical risk and quality assurance team in the Hospital. You are asked to be involved in a clinical incident review, and you are tasked to complete the following two items (NB: In your answers, you are to cite any relevant publications or materials);

Questions:

1. Analyse the above case in detail and identify and comment on the overall care administered to the patient. Identify any gaps in the quality of the care provided. You are also asked to comment on what “lines of responsibility” lay with all relevant individuals involved in this situation and;
2. Write a short but clear Risk Assessment (RA) document dealing with this case. The RA is aimed at all medical team members, GPs and will be used to advise consultant staff on the organisation of patients in such situations. In the RA, you are to point out the problems that occurred in the situation and, with advice and suggestions for practitioners, specify how these problems could be avoided for the future. You are also to make suggestions as to what systems can be put in place to help reduce the risk of similar issues arising again.