Mr M, a 44-year-old architect, attended his GP, Dr C, for a skin check. Dr C diagnosed a papilloma on his right chest wall as well as a seborrhoeic keratosis skin lesion of the upper left arm. A brief record was made in the notes, but there was no detailed description of how the lesion looked and no action was taken.
Five months later, Mr M was seen by another member of the practice, Dr B, for heartburn symptoms and Mr M also mentioned the skin lesion on his left arm. Dr B noted a “large crusty seborrhoeic wart with almost black hard surface and red flare around with warty texture”. There was no catching or bleeding. Dr B discussed removal with Mr M only “if it was a nuisance”.
The following month, a third doctor in the practice, Dr A, saw Mr M and referred him to the practice’s minor surgery clinic for removal of the lesion.
A month later, Mr M returned to the GP practice about the skin lesion – it had increased in size and was bleeding. Dr A prescribed flucloxacillin as he felt the lesion was infected. Mr M was referred urgently to a dermatologist. In the referral letter, Dr A wrote: “Pigmented lesion that he claims he has always had, although it was quite small. Over recent months it has increased in size and is now bleeding on occasions. It may be a malignant melanoma or squamous cell carcinoma. Can you see him as a matter of urgency?”
The day after the urgent referral was made, Mr M presented for minor surgery at his general practice, for the appointment that had been arranged by Dr A two months earlier. Only the crust of the lesion was removed as the doctor noted the possibility of squamous cell or “more likely a malignant melanoma”. The practice arranged for Mr M to be seen urgently by the dermatologist within two days. There were now palpable axillary nodes and melanoma seemed likely.
One month later, in March, Mr M underwent wide excision and axillary dissection, but his condition deteriorated. Unfortunately, he had developed brain metastasis by April and stage 4 malignant melanoma.
He died in July of progressive metastatic disease, despite chemotherapy and radiotherapy. Mr M’s widow made a claim against the doctors at the practice for failing to diagnose the lesion as malignant sooner.
Expert opinion
Claimant expert opinion was critical of the standard of care provided and felt that Mr M should have been referred straight away, rather than three months after the initial presentation. They also felt the earlier description of the lesion was not adequate or detailed enough, quoting NICE guidelines. Lifting the crust off the top of the lesion was criticised. However, expert opinion instructed by MPS felt that the overall outcome would not have been affected by a referral after the second GP consultation, given the rate and rapid progression of the disease by the time Mr M was first seen by the dermatologist.
In summary, the practice had been in breach of duty, but this breach was not the cause of death. The case was successfully defended.
Learning points
- Whenever a patient presents with a skin lesion, apply appropriate guidelines such as NICE’s seven-point checklist. Given Mr M’s age, the GP should have checked for and recorded anything sinister, especially as Mr M said he had always had the lesion. What had changed about the lesion that made Mr M attend the surgery for examination in the first place? This should have been investigated further and a full history documented.
- Meticulous record keeping is important, especially in relation to lesions and whether they are growing or changing in appearance. When referring, it is helpful to detail how the lesion looks in terms of size, colour and shape, rather than simply making a diagnosis. To find out more, MPS runs a workshop on Medical Records for GPs.
- Further reading: Watch out for the melanoma black spot, MPS Your Practice, (December 2012)