A v Enskat

In a clinical negligence claim concerning a testicular lump, the critical distinction was whether the abnormality was intra-testicular or extra-testicular. An urgent ultrasound or specialist referral was required where a lump was found in the testis, or where the clinician remained in doubt. Referral was not required where a competent examination identified benign epididymal thickening separate from the testis and the patient was adequately reassured. The claimant also had to prove that earlier investigation would probably have detected the tumour and avoided the fatal outcome. On the evidence, the examination was careful, the abnormality was an epididymal cyst, and the aggressive tumour was unlikely to have been detectable in 2002. The negligence claim was dismissed.

The claimant, the father and administrator of the estate of Ian, sued Dr Enskat for alleged clinical negligence. Ian had consulted Dr Enskat in October 2002 after noticing a lump in the right scrotal area. The claimant alleged that the lump was a palpable testicular tumour which should have led to urgent ultrasound examination or specialist referral. Dr Enskat recorded normal testes and slight thickening at the epididymis, reassured Ian, and made no referral.

A testicular tumour was diagnosed in August 2004. Ian later died from metastatic cancer. The central questions were whether Dr Enskat had failed to identify an intra-testicular tumour, whether referral was required, and whether earlier diagnosis would probably have prevented the death.

1. Claim dismissed. The claimant failed to establish breach of duty or causation on the balance of probabilities.
2. Dr Enskat conducted a thorough and competent examination. He examined both testes while Ian was lying down and standing, asked Ian to identify the area of concern, examined that area, distinguished the epididymis from the testis, and explained his findings with a diagram. The criticisms of his clinical note-taking did not undermine the reliability of his evidence.
3. The relevant clinical distinction was between an intra-testicular and an extra-testicular abnormality. The experts agreed that a swelling in the body of the testis, or uncertainty about its location, required urgent ultrasound or specialist referral. Where the clinician was satisfied that the abnormality was separate from the testis and represented benign epididymal pathology, referral was not required. Ian had accepted the reassurance and showed no continuing anxiety requiring referral on that separate basis.
4. On the evidence, the lump felt by Ian and his girlfriend, and identified by Dr Enskat, was the small epididymal cyst recorded in 1998 and again in 2004. It was not the malignant tumour later found within the testis. The claimant’s evidence concerning the location of the lump and Ian’s later diagram was unreliable when compared with the contemporaneous note, the examination evidence, the tumour’s pathology, and the anatomical features of testicular tumours.
5. The tumour was an aggressive, rapidly growing malignant teratoma with haemorrhage, necrosis and vascular invasion. The evidence did not establish that it had been present and detectable in October 2002, or that ultrasound at that time would probably have identified it. Calcification, necrosis, abdominal symptoms and the cited medical experience did not prove otherwise.
6. Accordingly, the claimant failed to prove that Dr Enskat negligently failed to investigate or refer, or that any such failure caused Ian’s death. The claim was dismissed.

not stated in the judgment.