Case study: Nose lesion

...Mr D complains of a non-healing lesion over the course of several months...

These case summaries are based on MDDUS files and are published here to highlight common pitfalls and encourage proactive risk management and best practice. Details have been changed to maintain confidentiality.

BACKGROUND

A 48-year-old construction worker – Mr D – presents at his GP surgery with a weeping spot on the right nostril. This was previously the site of a nose piercing that had been removed due to infection. His GP – Dr L – examines the spot and prescribes fusidic acid cream.

Two months later Mr D returns to the surgery and reports the spot has yet to heal. Dr L records: non-healing lesion on right side of nose; scab pulls off on dressing, etc. A swab is taken and Dr L advises the patient to purchase magnesium sulphate paste to apply to the spot. Results come back showing E. coli.

Two weeks later Mr D is back in the surgery and reports that he has been applying the paste and the spot is no longer oozing. Dr L prescribes an antibacterial ointment.

Over the next eight months Mr D attends the surgery twice for unrelated symptoms. He later claims that on both occasions he mentioned that the spot had still not healed, but was told it would get better on its own. This is not recorded in the notes.

Just over a year from the first presentation Mr D attends the surgery and asks to see a dermatologist. Dr L examines the lesion and makes a two-week cancer referral. A consultant examines the lesion and undertakes a punch biopsy, which later confirms a basal cell carcinoma of the nose.

Excision of the lesion is undertaken along with reconstructive surgery, leaving large and obvious facial scars. The prognosis is considered good.

A claim is later intimated against Dr L alleging clinical negligence in the delayed diagnosis of Mr D’s cancer. It is claimed that no competent GP would fail to instigate further investigation of a persisting lesion and this represents a breach of duty.

ANALYSIS/OUTCOME

MDDUS reviews the case and commissions expert reports to address both the breach of duty and causation (consequences of that breach). A primary care expert concludes that the care provided by Dr L fell below standard in that a non-healing lesion on the nose should be referred for excision biopsy, as this is a prime site for basal cell carcinoma.

A consultant dermatologist provides comment on causation, concluding that, had Mr D been referred and diagnosed with basal cell carcinoma at the second appointment, he would still have required surgery.

However, on the balance of probabilities, it would have been significantly less extensive.

MDDUS negotiates to settle the case with agreement from the member.

KEY POINTS

  • Be wary of non-healing lesions and follow accepted clinical guidelines on referral.
  • Record how your clinical decisions have been justified.
  • Make shared management decisions in discussion with the patient.
  • Record all matters raised by the patient during the course of a consultation and advice given in response – even if the patient raises a new issue as they are leaving the surgery.