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Monitoring of suspicious lesions by general practitioner (12HDC01533)
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(12HDC01533, 30 June
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
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
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
Adverse comment was made about the DHB's communication with the
woman prior to her surgery.