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Monitoring of suspicious lesions by general practitioner (12HDC01533)

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(12HDC01533, 30 June 2014)

General practitioner ~ District health board ~ Standard of care ~ Monitoring of lesions ~ Information ~ Communication ~ Rights 4(1), 4(4), 6(1) 

A woman presented to her general practitioner (GP) with an irregular shaped lesion on her lower right leg, which had changed in shape and size. Her GP examined the lesion with dermoscopy and said that it appeared to be a non-cancerous (benign) warty growth. The GP excised the lesion and sent a sample for histology testing. The histology result stated that melanoma could not be excluded in the tissue examined.

The woman said that the GP did not tell her the histology result or give her a copy of the report, and did not offer to re-excise the lesion. The GP's clinical notes are ambiguous as to whether he fully informed the woman of the histology result and her option of having the lesion re-excised. The record suggests that the GP told the woman that the lesion was clinically benign.

The GP felt that it was reasonable not to re-excise the lesion and to proceed with a plan to observe it closely and to re-excise it if he had any concerns, because the lesion was clinically and dermoscopically benign and there was no sign of residual lesion.

Nine months later, the woman drew the GP's attention to two lesions at the surgical site. Dermoscopy of the lesions was suspicious so the GP re-excised the lesion. The histology report confirmed that the lesion was a potentially serious form of skin cancer and so the GP performed a further re-excision with a wide clinical margin of 5-7mm. The histology report confirmed that there was no residual melanoma. No review arrangements were put in place.

A year later the woman returned to her GP. The GP performed a full skin check including dermoscopy. He was satisfied that there was no recurrence of the lesion.

Six months later, the woman presented to her GP with a new lesion at the surgical site. The GP observed no suspicious features. Two months later the woman attended a further consultation with the GP because she had a new irregular lesion on the same site. The GP noted that the lesion had grown and become irregular with suspicious dermoscopic features.

The GP sent an urgent referral to the plastic surgery department at a public hospital. An excision biopsy was performed. The results showed a 0.45mm invasive melanoma with no ulceration. A plastic surgery registrar recommended that the woman have a wider excision, including reconstruction with a split skin graft.

Prior to the surgery, the woman was not given the DHB's information sheet, which advises that the surgery requires complete rest for a week with the leg elevated, and very limited standing.  However, the information was provided after the surgery.

The woman was discharged from hospital. A few days later the wound became infected and was treated with antibiotics. The woman suffered a loss of skin graft and she had to return to the hospital a further two or three times. Eventually the wound healed, but the woman was left with a severe scar.

It was held that the GP's decision to observe the lesion rather than to re-excise it was unsafe, and a departure from the accepted standard of care. When the woman expressed concern about a new lesion the delay in referring her to the hospital was a severe departure from accepted standards. For these reasons the GP breached Right 4(1). The GP should have ensured the woman was aware, and understood, that the histology report stated that melanoma could not be excluded. He should also have discussed the option of a re-excision of the lesion, including the risks and benefits of that option, and clearly documented the discussion. This was information that a reasonable consumer would expect to receive and by failing to provide the woman with that information, he breached Right 6(1).

The GP failed to put in place a structured monitoring plan for the woman and in failing to do so, he did not take sufficient steps to minimise the risk of harm to the woman and breached Right 4(4).

Adverse comment was made about the DHB's communication with the woman prior to her surgery.



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