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Two Oncology Case Reports

Medico Legal

by Dr John P Glees MD FRCR DMRT Consultant Radiotherapist and Oncologist, Honorary Senior Lecturer

Dr John Glees is a Clinical Oncologist. He specialises in treating patients with all types of cancer.

Using radiation therapy and chemotherapy and is also a specialist treating benign conditions with superficial radiation such as Dupuytren’s disease, a collagen disorder affecting the hands and fingers which if successfully treated in its early stages replaces the need of a Hand Surgeon. Dr Glees also provides medical legal opinions in patients with cancer and other conditions.

Case one
A female patient in her mid forties was referred for treatment of hyperthyroidism. She was thyrotoxic and was referred to me for consideration of treatment
using radioactive iodine. I agreed that this was the treatment of choice.

Her history, as in all patients, was of great interest to me. She told me she had a baby daughter aged under two who was currently in the Intensive Care Unit of a major London teaching Hospital suffering with fits and some brain damage. Her child was very ill and she feared for her daughter’s life. She told me that she was an unmarried mother and clinically my initial impression was that she was very thyrotoxic confirmed on the blood tests.

Her thyroid condition had only recently been diagnosed because she had presented with exophthalmos, tremor, weight loss and a palpably enlarged thyroid gland with a very raised serum thyroxine level.

She told me she was expecting a prison sentence! I asked her why. She told me that the previous week she had been in front of a jury in the Crown Court at Southwark and had been found guilty of theft by the jury with a majority verdict. The Judge had told her to expect a prison sentence and she was to return to the Court to hear the sentence the following week.

I asked whether her Lawyer knew that she was suffering with an overactive thyroid and she said ‘no’. I explained to her that when one is suffering with thyrotoxicosis, one can have an episode of “thyrotoxic madness” in which one did things not normally done, for example stealing. I asked her what she had stolen and she told me she had befriended an old lady whom she had met in the street whilst out shopping and had been invited by this lady to her house for a cup of tea. She had subsequently been accused of stealing this lady’s valuable necklace. She told me that the old lady had given her the necklace as a present!

I asked for her permission to write to the Judge, whose name she knew, and to let him know that she was suffering with an acute thyrotoxicosis which had been unrecognised at the time of the theft and couldhave explained the reason that out of character she had taken the necklace. She agreed to this.

I wrote to the Judge and two weeks later I got a telephone call from the Judge asking me to come and see him as a matter of urgency. I ask where should I come and he said that he had slipped his disc and was an inpatient in St Thomas’ Hospital in London and her Court case and sentencing had to be delayed until he was better.

He requested that I urgently visited him and I went to St Thomas’ Hospital to his bedside. He had a private room with a lovely view of the Houses of Parliament through the window. I told him about her thyroid condition and that bouts of so called “thyrotoxic madness” were not uncommon in this condition and this could perhaps explain the reason for the theft.

The Judge became very excited to hear this and said it was of the utmost importance that I attend the Court proceedings as soon as he was discharged from Hospital.

About six weeks later I was asked to attend Southwark Crown Court and was ushered in to be called forward by the Judge now dressed in all his regalia. He looked very different from when I last saw him at St Thomas’ Hospital especially now wearing a wig!

After I had sworn on the Bible to tell the truth and nothing but the truth, the Judge admonished all the Lawyers and especially her defence Lawyer for knowing nothing of her medical condition.

“Were it not for Dr Glees writing to me whilst I was recently recovering from a slipped disc operation at St Thomas’ Hospital, none of us would have been aware of her medical illness and it was highly likely that a miscarriage of justice would befall her”.

He told the Court that he took this most seriously and was profoundly cross with all the Lawyers, who were then called to come up before him to the bench. The whole Court room was hushed and astounded by this turn of events. He then recommended an adjournment for one hour when he expected the Lawyers to have reviewed her case, taken into consideration what I had told the Court and return to him with the relevant literature references so that he could then proceed.

We waited anxiously for the hour to pass. The patient looked at me with glowing eyes, the woman from whom it was said she had stolen the necklace and all her relatives glowered at me with marked hostility apparent. I was a surprise witness called by the Judge himself to whom I had also given references of this condition of thyrotoxic madness as everyone was expecting a prison sentence to be passed.

When the Judge returned he thanked me for providing the Court with this new important evidence and again he admonished the defence team that this lady was ill and suffering from a condition possibly causative as to the charge of theft. “Imagine” he said “this is very grave. I could have passed a prison sentence on her and again I repeat a grave injustice could have occurred”.

With that he banged the gavel on the desk and drew attention of the Court to his summing up and told everyone in Court to be quiet.

He said that thanks to me an explanation to a crime occurring had been given and instead of prison he was recommending probation for 18 months. With that “all hell” broke out in the Court room with an ongoing shouting of the other side’s relatives. “Order, order” said the Judge. “Dr Glees, you are now excused. The Court is most grateful for your important evidence and we all owe you a great deal of thanks in alerting us to her condition and thus saving a gross injustice from occurring”.

The Judge went on “let this be a lesson to all of you Lawyers in this Court room that you must be certain that you know full facts including relevant medical facts which should have been presented to me (the Judge) and to this Court. Had it not been that I had slipped my disc and that the sentencing had been postponed, I can only repeat that a grave injustice would have been carried out in the name of the Queen and the Court”.

“Dr Glees you may go now”. “Thank you” I said to the Judge but I want to stay and hear the rest of the case and he said to me “certainly you can stay but we will only pay you for the morning session”. “I thought” said the Judge “that you would need to get back to your busy Clinic at the Hospital”. I told him that I had taken the day off especially to be present. “Very well” said the Judge “stay and keep quiet”.

Much to my amazement, the previous convictions which she had were read out (I had not been told that she had any). She had been accused and found guilty of stealing money from Barclays Bank some years previously when she had worked as a counter clerk. At that time she had also been given probation in view of her circumstances.

At the end of the proceedings I left the Court and carefully avoided the seething relatives of the lady whose necklace and some money she had stolen.

The patient went on to make a full recovery following two courses of radioactive iodine and her thyroxine levels returned to normal range. She was also able to look after her child.

Case 2
The second case is that I was asked to give an opinion on a 37 year old lady who had been referred by the GP to a Breast Clinic because she was concerned about a rash around her nipple and also blood staining as a result of the rash inside her bra.

She was seen in the Consultant’s Breast Clinic by a Registrar who took the history but unfortunately miscalculated or misunderstood her age. The Registrar thought she was 29 when in fact she was 37.

The patient had complained of a rash like irritation over the areola area of the breast, the central part of which is the actual breast nipple. The areola is usually a little raised and a darker brown colour than the white appearing skin of the breast. The Registrar was of the opinion that the rash was significant but failed to make an adequate drawing or take a photograph. The Registrar also thought that she could feel a significant lymph node in the axilla.

The patient was very anxious that she could have breast cancer because the rash had been present for nearly 18 months and the GP had eventually referred her for investigation at the Breast Clinic. The patient had requested that a mammogram be done.

The Registrar asked the Consultant, who was in an adjoining Clinic room, to give his opinion. The Consultant looked at the breast said “not breast cancer” and told the lady that a mammogram was not needed. When the patient asked again for a mammogram the Consultant told her that she was too young and did not fit within the protocol!

The patient’s breast irritation continued and 8 months later she was again referred by her GP to the same Breast Clinic but seen by a different Consultant. The areola area was reddened and appeared infected and there was some crusting and it bled easily so she was sent for an urgent ultrasound and mammogram. Both these investigations confirmed cancer. She required a mastectomy and the cancer was now 10cm in diameter and the lymph nodes removed from the axilla were positive.

There was a significant 8-10 months delay in making this diagnosis.

Having carefully read all her notes in great detail and the description of the findings of her nipple and areola, I was certain that they (the initial Doctors in the Breast Clinic) had missed the diagnosis of Paget’s disease of the nipple first described by Sir James Paget in 1879. This is a classic finding and both initial Consultant and Registrar missed it and were guilty of failing to give this patient proper and reasonable care.

Paget’s disease of the nipple is really a skin cancer, Pagetoid, affecting the areola of the breast but there is always an underlying breast cancer present, as was the case in this lady. The hallmark of Paget’s disease is the actual inflammatory like redness affecting the areola and nipple and there is crusting and when
touched there may be bleeding.

I had sent a photograph of the appearance of Paget’s disease to the Lawyers which was used in evidence.

The Medicolegal Team had to attend Court as the Hospital and in particular the Breast Clinic did not accept guilt. As far as I was concerned this lady’s case fell far short of that which is accepted as standard care and which should have been available to her in the specialised Breast Clinic.

The delay in her case caused the cancer to spread into the lymph nodes and the bones and now unfortunately also to the brain. Sadly she will die prematurely.

She also attended the Court hearing and she wanted to meet me and it was my pleasure to do so and I was pleased to shake her hand and pleased to know that
I was able to help in her case.

The Judge found in our favour and she was awarded over a million pounds. This will help her family at least.

It was my medicolegal opinion that the 8 – 10 month delay in missing the diagnosis of breast cancer in a patient who already gave an 18 month history of
symptoms affecting the breast when she saw her GP for the first time, was 50% causative in allowing the cancer to grow and spread to the lymph nodes and metastasise also to the bones, and now to the brain. Her GP had not recognised the significance of her symptoms that were affecting her breast and had treated her for a skin infection before she was actually referred to the Specialist Breast Clinic for the first time where her disease was again sadly not recognised as such, and now after a very significant delay in making the appropriate diagnosis, she is suffering with metastatic breast cancer and will die at an early age.

Earlier recognition that she had breast cancer when she was first referred to the Specialist Clinic, may have saved her life.

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