Over the period from March to May 2005, the claimant, an inmate in prison, saw three different doctors complaining of a lump in her breast. None of the doctors referred the claimant to a specialist. After her release from prison some months later, the claimant was diagnosed with a ductal carcinoma in her right breast and underwent a mastectomy.

The judge held that there was no evidence of negligence on the part of the doctors who saw the claimant in March and April. However, the doctor who examined the patient in May was negligent in not taking a medical history. Such a history would have elicited the fact of earlier consultations and established the location of the possible lump. If this had been done, the doctor would have made the claimant the subject of a non-urgent referral to a breast clinic. Her failure to do so was a breach of duty and was negligent. It was important, when conducting a fact-fi nding exercise, to bear in mind the realities of a prison environment. Although a fi nding of liability was made, the case is interesting because the judge accepted that, as the prison’s healthcare department had a transient patient population of frequent attendees and as the healthcare department relied, as it did, on handwritten records, it would have inevitable diffi culties in maintaining complete and explicit records.

Cheryl Carter v Ministry of Justice [2010]