Carter v Ministry of Justice

A general practitioner assessing a possible breast lump must take a history sufficient to identify relevant earlier consultations and the location and persistence of the concern. Even where examination reveals no sinister feature, reasonable care may require a routine specialist referral if the history shows a sustained, unresolved concern. Such a referral is not automatically mandated and need not be urgent where examination is reassuring. The assessment depends on the overall circumstances, including the significance of the possible condition and the practical ease of obtaining a second opinion.

The claimant alleged that medical officers at a prison negligently failed to respond appropriately to repeated complaints concerning a lump in her right breast. She contended that earlier referral would have produced a materially better cancer prognosis. The trial was confined principally to liability, with causation and quantum left for later determination or agreement. The central issues were whether the claimant had made the alleged complaints and whether the treatment provided by the doctors, particularly the final consultation, fell below the required standard of care.

1. The claimant established that she had complained of a right breast lump to Dr Munasinghe, Dr Jayasinge and Dr Premaratne. The absence of records did not justify rejecting the first two complaints because the prison records were incomplete and unreliable in the circumstances.
2. Negligence was not established against Dr Munasinghe or Dr Jayasinge. The evidence did not permit a reliable finding about the examinations or the clinical features present at those consultations.
3. Dr Premaratne had exercised reasonable care in examining the breasts and, on the evidence accepted, the axilla. The absence of sinister findings did not itself establish negligent examination.
4. Dr Premaratne was nevertheless negligent in failing to take a history which would have disclosed the earlier consultations and located the possible lump. On that history, reasonable care required a non-urgent referral to a breast clinic. An urgent referral was not required because the examination had not disclosed anything sinister.
5. The court rejected the suggestion that referral was mandated automatically by a fixed rule or a supposed rule of three. The conclusion followed from the overall circumstances, including the sustained unresolved concern, the potential significance of a breast lump and the relative ease of arranging a routine specialist opinion. The court noted that this balancing approach had parallels in Morris v West Hartlepool Steam Navigation [1956] A.C. 552 at 574.
6. Breach of duty was therefore proved against the defendant in respect of Dr Premaratne’s consultation. Issues of causation and quantum remained to be resolved, with the parties encouraged to settle.