A foregone outcome?

Mrs J attended her GP – Dr L – with a mole on her back that her husband had noticed was changing in shape and colour.

Dr L diagnosed a pigmented papilloma and advised Mrs J to make an appointment to have it removed at the practice’s minor surgery clinic. The patient spoke to the receptionist who informed her that there were no free slots in the next clinic and, as the practice did not operate a waiting list system, she would have to call the surgery every week to see when a slot would be available.

Mrs J phoned the clinic numerous times over the next two months but there were never any slots. In the meantime she noticed the lesion was changing more rapidly in colour and shape and starting to protrude. She told the receptionist of her concerns but these were not noted or passed on. Her husband eventually insisted she make another appointment with Dr L.

In the next consultation the GP noticed the changes and immediately referred Mrs J to a dermatology clinic where it was excised the same day. The histology report confirmed an invasive malignant melanoma. Fine needle aspiration of a lymph node in the left axilla determined that the cancer had spread.

Mrs J was admitted to hospital for block dissection of the lymph node as well a re-excision of the scar where further melanoma deposits were found. Over the next months there was rapid metastatic spread to the lungs, liver and bone. Mrs J died at home within 10 months of first seeing the GP.

Her husband instructed solicitors to bring a claim of medical negligence for misdiagnosis and failure to refer. It was alleged that had Mrs J been referred at the initial consultation there would have been no subsequent lymph node involvement and spread of the melanoma.

Analysis and outcome

MDDUS acting on behalf of the GP commissioned reports from both a GP expert and an oncologist. The GP expert was of the opinion that, given the location and changing nature of the lesion, Dr L should have made an immediate referral. He also was critical of the booking arrangements for the minor surgery clinic and the fact that Dr L was not alerted as to Mrs J’s concerns over the developing lesion. Given these facts the expert felt there was a breach of duty of care to the patient.

The oncologist agreed that the lesion should have been diagnosed earlier but was of the opinion that the delay would have made no difference to the overall outcome of the disease in either cure or prolonged survival. It was an extremely aggressive melanoma.

The case was subsequently discontinued by the pursuer without explanation.

Key points

• Have a high degree of suspicion with any skin lesion said to be undergoing recent change in shape or colour – if in doubt, refer.
• Ensure that practice systems do not lead to significant ongoing delays in treatment.
• Instruct staff to report any significant patient concerns to the relevant GP
• It is important to consider in each case whether or not any fault by a practitioner led to any altered outcome. In this case, sadly, the patient's outcome was pre-determined by the aggressive nature of the disease.