Suspicious mole

BACKGROUND: A 42-year-old man – Mr T – makes an appointment at his local GP surgery. He is worried about changes in a mole on his right thigh. It is about the size a five pence coin and has been present since childhood. In the last few weeks he has noticed that the mole has become darker in the middle and seems to be spreading outwards.

Mr T is attended by his regular GP – Dr N. She examines the patient and records: “1.5 cm raised, pigmented lesion. Needs excision. Refer to dermatology”. Dr N makes a non-urgent referral for the patient to see a consultant dermatologist – Dr B.

In a local hospital outpatient clinic Mr T is seen by Dr B. He tells the dermatologist that the mole has grown “crusty” and bleeds when he catches it on the bath towel. On examining the mole he records: “1.5 cm papillomatous congenital type naevus on right anterior thigh. Mole appears benign.” He tells Mr T that the mole is nothing serious and that removal is not necessary unless for cosmetic reasons. The patient replies that he is not bothered by how it looks as long as there is no risk.

A few months later the mole begins to bleed again. One morning it appears to have “burst” and there is blood on the bed clothes. Mr T returns to the GP surgery on the insistence of his wife. Dr N suggests it may be infected and prescribes an antibiotic. There is no reference in the patient records to bleeding or any significant change in the mole but the GP makes another non-urgent referral to the dermatologist.

Dr B examines the lesion and agrees to slice the top of the mole off and cauterise the wound to stop the bleeding. But Mr T insists he wants the lesion removed entirely. The patient is put on a surgical waiting list and two weeks later there is a cancellation. A surgeon removes the lesion in a minor procedure. A biopsy reports indicates a nodular malignant melanoma in vertical growth phase with incomplete resection margins.

Wider excision is required along with sentinel node biopsy (negative). A later CT scan of the thorax, abdomen and pelvis shows no sign of metastases.

ANALYSIS/OUTCOME: A letter of claim for damages is issued by solicitors acting for Mr T alleging negligent medical treatment against both Dr N and the local hospital trust.

The letter states that the dermatologist was negligent in not arranging for the lesion to be urgently excised after both the first referral and subsequent referral given major red-flag symptoms including recent changes in a permanent mole with asymmetry and irregularity in shape, border and colour. It is further alleged that the GP was negligent in failing to urgently refer Mr T after his second visit to the surgery resulting in a three month diagnostic delay.

Mr T currently shows no signs of disease but staging of the disease indicates that his life expectancy at five years has been reduced by 43-47 per cent.

MDDUS solicitors acting for Dr B commission a medico-legal report which is broadly supportive of the GP though the expert finds fault in the lack of details in the patient records on the progression (or lack of) of the lesion. But the expert opines the non-urgent referral was probably reasonable in the circumstances given the recent consultant assessment and diagnosis stating the lesion was benign.

MDDUS solicitors send a firm rebuttal of the allegations against Dr B and these are dropped, though Mr T continues the pursuit of his claim against the hospital trust.

KEY POINTS

• Record all referral decisions and the reasoning behind these.
• Have a high degree of suspicion with any skin lesion said to be undergoing recent change in shape or colour – if in doubt, refer.
• Referral delays in cases of malignant melanoma seriously reduce survival.