"Dr C did not take action on the abnormal result until February 14, 2014 -- when he was reminded of the result a second time by his practice nurse -- at which point he asked Mr A to return for a follow-up appointment," Mr Hill says.
The GP referred the man for urgent investigations, which revealed a malignant stomach tumour. While the man was waiting for further investigations to determine the stage of the cancer, new symptoms emerged and a CT scan revealed the disease had spread to his brain.
"Sadly, Mr A died later that year."
Mr Hill says Dr B's breaches of the code were his failure to take steps to find the possible underlying cause of his patient's anaemia, not organising follow-up to assess his response to treatment and failing to discuss with the man the potential implications of the results of blood tests taken in October 2012.
Dr C's breach was the nine-week delay in following up the abnormal December 2013 test results.