CASE FILES CLAIM SUSPICIOUS FRECKLE
BACKGROUND A 48-year-old woman – Mrs K – attends the GP surgery with her young daughter, who is suffering with a persistent cough. The GP – Dr F – examines the child and offers reassurance that it is likely a viral infection and will clear in time with symptom control. Just before leaving, Mrs K asks the GP if
he would check a “freckle” in the scapular area of her own back as she is worried it has grown larger and changed in appearance in recent months. Dr F undertakes a quick examination and diagnoses a “warty lesion” – instructing Mrs K to book an appointment to have it removed by cryotherapy. Two weeks later Dr F treats the lesion with liquid nitrogen and Mrs K is advised to allow it to scab and fall off at home. Two years later Mrs K attends the
surgery concerned over a small lump under her right axilla. Dr F examines the lump which is diagnosed as a lipoma. The GP makes a non-urgent referral to the surgical unit at the local hospital and Mrs K is put on a waiting list – but three weeks later she returns to the surgery concerned that the lump is enlarging. A different GP examines the lump and suspects an enlarged lymph node. He expedites the referral to an urgent two-week cancer wait. Mrs K is seen at the local hospital and the
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lump is biopsied. This indicates the lesion is metastatic spread of a malignant melanoma – most likely the “warty lesion” removed by Dr F two years previous. Mrs K undergoes axillary lymph node dissection and removal of the nodal mass but she later develops further axillary and lung metastases and dies just over a year later. Dr F subsequently receives a claim for damages on behalf of Mrs K’s family alleging clinical negligence in her care. It is alleged that the GP failed to consider that the initial lesion might be cancerous and thus refer the patient for excisional biopsy. Dr F also neglected to adequately record the lesion, including shape, size and growth. The subsequent delay in diagnosis allowed the cancer to progress such that the prognosis was poor.
ANALYSIS/OUTCOME MDDUS acting on behalf of Dr F instructs a GP expert to review the case, including the patient notes and letter of claim. She finds that the medical records are unacceptably brief, stating only that Mrs K presented with a “warty lesion” on her back which was later treated by cryotherapy. In the letter of claim it is alleged that Mrs K complained of a “freckle” that had become raised and enlarged, with oozing. The expert comments that this would not be the appearance of a viral wart and – given
the change in size, shape and colour and reported oozing – such a lesion as described would certainly have merited excisional biopsy. She concludes that in the absence of a
contemporaneous record regarding the appearance of the lesion and given the description in the letter of claim, Dr F’s actions would be difficult to defend. A consultant dermatologist is also
instructed to offer a view on causation (consequences of any breach of duty of care). It is his opinion that the scapular lesion was likely a misdiagnosed melanoma which may have regressed in response to cryotherapy, but over the subsequent two years spread to the lymph nodes and lung, resulting ultimately in the patient’s death. MDDUS decides with agreement of the member to settle the case.
These case summaries are based on MDDUS files and are published here to highlight common pitfalls and encourage proactive risk management and best practice. Details have been changed to maintain confidentiality.
KEY POINTS ●Record a detailed description of skin lesions including size, colour, shape. ●Be suspicious of any description of change in an existing mole or freckle. ●Consider the need for excisional biopsy to rule out melanoma or other forms of skin cancer.
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