The woman told this doctor that, although not painful, her breast lump had increased in size. The doctor examined the woman and told her to monitor the breast lump, but did not refer her for further investigation.
A few months later the woman consulted her regular GP again complaining of a swollen and painful right upper breast and armpit, and that the lump felt a little bigger.
The regular GP referred the woman for further investigation, and the woman was diagnosed with invasive breast cancer.
She underwent urgent chemotherapy followed by surgery and radiation.
Deputy Commissioner Allan considered the second doctor had a responsibility to refer the woman for further investigation and provide services with reasonable care and skill - but failed to do so.
As a result of his findings, Allan recommended the doctor provide documentary evidence of having completed continuing professional development on breast cancer management. The doctor was also advised to provide a written letter of apology to the patient.
The doctor told the Health and Disability Commissioner (HDC) that he/she accepted that he/she should have followed a more thorough approach.
"I acknowledge that [the patient] should have had imaging organised instead of further monitoring the lesion. I do sincerely regret this omission.
"I wish to apologise to [the patient] about not making a referral for imaging and the likely delay in diagnosis that occurred.
"I hope that my response, and in particular, the efforts that I have made, (and continue to make), reassures [the patient] that I am doing all I can to ensure that I do not make a similar mistake again."
Although the doctor was found to have breached the Code, the medical centre itself was found to have taken such steps as were reasonably practicable to prevent the particular errors that led to the breach.