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Source: MIL-OSI Submissions

Source: Health and Disability Commissioner

The Office of the Health and Disability Commissioner released a report today finding a general practitioner (GP) in breach of the Code of Health and Disability Services Consumers’ Rights (the Code) for failures in his care of a patient with suspected melanoma.
The man, who had a complex medical history, was reviewed by the GP at a medical centre. As part of the consultation, the GP examined a skin lesion on the man’s arm and considered it to be a wart. Some months later, the man re-presented to the GP, who noticed that the lesion had changed considerably since the last consultation. The GP was concerned by these changes, and took photos of the lesion and offered to remove it for a fee, or refer the man to the local hospital.
The man opted for a hospital referral. Unfortunately, the GP failed to upload the photographs to the man’s file or complete the referral form. Three months later, the man was seen at the same clinic by another GP, who was unable to confirm that the referral had been sent. The first GP was called in and acknowledged that he had not sent the referral. He took new photographs and actioned an urgent referral. It was later confirmed that the lesion was a malignant melanoma. Fortunately, there was no evidence of residual malignancy or metastatic disease.
Former Commissioner Anthony Hill considered that the GP had failed to initiate a referral to the hospital in a timely manner, failed to document his findings, and did not let the man know the timeframe in which he could expect to receive an appointment following the referral to hospital. These oversights meant that there was a delay in the man receiving treatment for his malignant melanoma. Accordingly, the GP was found to have breached the Code. Mr Hill acknowledged the otherwise high standard of both documentation and clinical practice by the GP, and commended him for his open disclosure of his failure to send the referral.
Mr Hill recommended that the GP implement the use of a reminder system as soon as the intention to make a referral has been confirmed, and provide a written apology to the man.
The full report for case 19HDC01050 can be found on the HDC website.