oct ewj 24 online - Flipbook - Page 33
patient subsequently claimed for delayed diagnosis by
the GP and hospital with inappropriate escalation to
further cross-sectional imaging. The basis of the claim
was disproportionate symptoms to a Baker’s cyst, failure to re-examine, and inaccurate reporting of the
ultrasound by the Sonographer.
During the procedure, it was difficult to excise and an
attempt at best excision was made and sent to pathology which revealed a soft tissue sarcoma. She was subsequently referred onwards to the sarcoma centre
locally for onward management. The patient claimed
for incorrect diagnosis and diagnostics with the lack
of consideration for a repeat scan especially MRI scan,
in view that the lump has changed, increased in size
and became more painful.
Case number 2
A 42-year-old lady had been presented with left leg
sciatica symptoms, and mild to moderate back pain for
two months. She was assessed by the GP who had diagnosed her with having generalised lower back pain,
possibly sciatica, and was prescribed analgesic and
physiotherapy.
Introduction:
The issue of delayed diagnosis in cancer, in particular
sarcoma, is a recurrent theme in medical negligence.
Sarcoma is a rare cancer hence difficulty in diagnosis
can occur; however, as per NICE guidelines any lump
which is getting bigger in size, deep and painful, or has
a suspicious initial diagnostic should be referred for
opinion to the local sarcoma centre as a suspected case.
As her symptoms were not settling, she was
subsequently referred for an MRI scan of her lumbar
spine which was deemed normal and no obvious explanation for her sciatica was explained. The report
was sent to the GP.
The above examples highlight that there are many
pitfalls in relation to sarcoma diagnosis, particularly in
primary and secondary care.
She was subsequently reassured by the GP and sent
for further physiotherapy. Her symptoms persisted
for another two months with persistent leg pain down
to her ankle with paraesthesia and numbness with
progressive weakness at the base of her foot, particularly on tiptoeing suggesting a sciatic nerve problem.
Observations on previous sarcoma clinical negligence
cases revolve around delayed referral of the patient
for diagnostics or specialist input, absence of suspicion
that this could be a soft tissue or bone sarcoma, not
taking appropriate history with regard to the patient
to suspect that this could be a sarcoma, and misinterpretation of diagnostics and delayed diagnosis.
In view of ongoing symptoms, she presented to her
local A&E Department who assessed her and in view
of her symptoms, repeated the MRI scan of the lumbar spine. Fortuitously, the MRI scan of the lumbar
spine also included images of the proximal thigh on
the left side. This included at the inferior aspect a
possibility of a soft tissue mass.
Exploring these themes further:
Delayed referral:
One of the most common causes of litigation is
delayed referral from the initial consulting clinician
(e.g. GP, Consultant) or allied health professional, who
may have just a lump, swelling, or even symptoms
relating to possible bone cancer, which have led to the
delayed referral.
This was red-flagged and subsequently escalated to
the local orthopaedic surgeons who reviewed her in
clinic and arranged an MRI scan of her thigh. Fortunately, the orthopaedic surgeons are also part of the
local sarcoma centre, and she was urgently referred
on the suspected cancer pathway.
It is imperative to take a detailed history and
acknowledge that a lump which may be increasing in
size, is bigger than 5cms or has re-occurred after previous excision as if this is not carried out, it can lead to
further delays and a missed diagnosis of a possible
potential cancer/sarcoma.
The MRI scan of the left thigh revealed a large
heterogeneous soft tissue 20cm mass in the posterior
aspect of the proximal thigh. Features were consistent
with soft tissue sarcoma and subsequent biopsies and
discussion at MDT went on to having a wide resection.
Pathways put in place along suspected cancer
pathways across England to allow general practitioners to refer into secondary care and sarcoma centres
for patients with suspected sarcoma. Failure to refer
on these pathways may lead to further delays.
The patient claimed that there was a delay in
diagnosis with regard to her symptoms and absence of
physical examination by the primary care physician.
Case number 3
The third case revolves around a soft tissue lump on
the left thigh, which was initially several centimetres
in size and referred with the skin changes to the local
dermatologist. This was assessed by a Dermatologist
who deemed this to be a sebaceous cyst. The patient
wanted to have it excised and was subsequently listed
for excision under local anaesthetic. An initial ultrasound scan was performed, which was suggestive of a
sebaceous cyst.
The indications for referral for a possible bone
sarcoma includes X-ray showing suspicious findings,
bone pain, and limb/joint swelling. Night pain in a
limb or joint should not be ignored.
It is particularly important to note that such tumours
are not missed in the paediatric and young adult
population.
It is commonplace when asking patients about their
journey that they state that they have seen multiple
medical professionals with regard to their symptoms
and reassured that nothing is wrong.
When the patient presented for surgery, the lump had
tripled in size to approximately 8cm with erythema
and increasing pain. Local excision as planned was
attempted by the Dermatologist.
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