A misfiled result - medical case study

...The histology report indicates a malignant melanoma, but the letter is filed away and is not checked for several months...

  • Date: 31 January 2011

A 39-year-old woman visits her GP, Dr A, with concerns about a wart-like lesion on her left leg. Dr A excises the lesion and sends it for histopathology. A couple of weeks later Miss E’s results arrive at the practice but Dr A is off on sick leave. His mail is distributed amongst the two other GP partners, in line with practice procedure. The histology report indicates a malignant melanoma but the letter is marked with a tick indicating it is to be filed. The histopathologist attempts to contact the practice on two occasions about the result but receives no response. The report is filed in Miss E’s medical records and no further action is taken.

The patient visits Dr A three times in the following months about various health concerns, including a new lump on her left leg. Dr A eventually discovers the report indicating melanoma during one of their consultations – after a delay of three months. He immediately refers her to an oncologist but the cancer has spread. Miss E undergoes chemotherapy and surgery but the prognosis is poor.

Miss E raises a claim alleging clinical negligence and breach of duty of care. The practice investigates but is unable to determine who marked the histology report to be filed.


Dr B, an MDDUS member, is one of the practice’s three GP partners, and it is agreed he must share responsibility for any practice system failure. The other two partners, including Dr A, are not MDDUS members but belong to the same MDO. That MDO commissions expert reports from a GP and cancer specialist. The GP report finds there was a practice system failure that led to the histopathologist’s report not being acted upon. Dr A is also criticised for not checking the histology result at subsequent consultations with Miss E. The cancer expert’s report says that while the delay in treatment would not have affected Miss E’s chances of survival, it meant her quality of life suffered considerably due to the complex treatment required at that stage of her illness.

MDDUS agreed with the other MDO that the case was indefensible due to the delay in treatment caused by the misfiled report. A settlement was agreed and MDDUS paid a one-third share on behalf of Dr B.

Key points

  • Ensure a robust system is in place for dealing with all laboratory and histology reports going in and out of the practice and be sure it stops results from being filed without action.
  • Advise patients to contact practice to find out test results within a specified time frame.
  • Ensure sign-off by all staff members when amending patient records.

This page was correct at the time of publication. Any guidance is intended as general guidance for members only. If you are a member and need specific advice relating to your own circumstances, please contact one of our advisers.

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