Rectal bleeding - missed referral

01 May 2007

A 42-year-old female patient, Mrs L, attended her GP complaining of rectal bleeding. This was bright red with no associated symptoms. The patient was otherwise in good health. On examination, including rectal, no abnormality was found and a presumptive diagnose made of haemorrhoids.

Mrs L attended for various other medical matters and later presented with weight loss and feeling tired some eighteen months after her first presentation with rectal bleeding. On examination only minimal weight loss was noted. No further examination was documented.

Shortly after this appointment Mrs L telephoned and asked for a prescription to treat constipation. This was provided after a discussion with her GP who asked the patient to attend the surgery.

At review Mrs L confirmed a history of constipation and that in addition she had rectal bleeding. The GP noted her earlier diagnosis of haemorrhoids. No note was made of any examination being carried out. The patient was referred for surgical review.

At surgical review, three months later, Mrs L was diagnosed with colorectal carcinoma. She required extensive investigation, radiotherapy and surgery. During this time she intimated a claim for negligence alleging delay in the diagnosis of colorectal cancer.

Analysis and outcome

Ultimately settlement was negotiated with the patient because of several weaknesses in defending the case:

• Lack of appropriate notes - in particular failure to record what, if any, examination was carried out prior to referral. Also the patient alleged that she complained of constipation and rectal bleeding at a number of consultations but this was not noted nor acted upon.
• Failure to refer the patient urgently when surgical opinion was sought. A combination of recent change in bowel habit and unexplained rectal bleeding should have prompted the GP to send an urgent referral.
• Expert opinion was that sadly an urgent referral would not have significantly affected the outcome for the patient. However, had the patient been referred when she first presented (routine referral) it was likely that her tumour would have been picked up at a time when she would have had significantly less disease.

Key points

• Keep adequate notes.
• Be aware of clinical guidelines for routine/urgent referrals.
• Take care to ensure a complete history is taken addressing all salient symptoms.
• Be aware of unexplained rectal bleeding.