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Source: MIL-OSI Submissions

Source: Health and Disability Commissioner

The Health and Disability Commissioner today released a report finding a general practitioner (GP) in breach of the Code of Health and Disability Services Consumers’ Rights (the Code) for failures in his treatment of a woman, leading to a delayed diagnosis of skin cancer.
The woman, in her eighties, visited the GP for removal of a lump behind her ear, which she had had for several years. The GP removed the lesion, which he had diagnosed as a sebaceous cyst. He did not follow the medical centre’s standard practice and cut the cyst open to confirm the diagnosis visually, and he did not send the excised tissue for histological examination to determine whether it was benign. After excising the lesion, the doctor told the woman that he intended to dispose of the sample, but she asked to keep it.
After the excision, the woman started to notice changes in the area where the cyst had been removed, including itchiness, tenderness, swelling, and pain. She visited the medical centre on three occasions about this, and was seen by three different doctors, including the GP. On the fourth occasion the woman presented, another GP reviewed the woman and noted ongoing issues with pain and swelling, and a further lesion around the site. She referred the woman to the Plastics Department of the public hospital, but the referral was declined with a note saying the history was unclear and that the GP should re-refer if she suspected malignancy. The GP did so, and the referral was accepted.
Nearly two years after the lesion was removed, the woman presented the original sample that she had kept to the Plastics Clinic. Histological examination was carried out, and the woman was diagnosed with stage 4 metastatic melanoma (skin cancer).
“[The GP] made an error by not confirming the cystic content of the specimen before deciding not to send it for histology, and not documenting that decision in the clinical notes,” said former Commissioner Anthony Hill. “This resulted in a delayed diagnosis for [the woman].”
The Commissioner found that the GP failed to provide services to the woman with reasonable care and skill. He recommended that the GP provide relevant evidence to demonstrate appropriate management of minor surgery and histological analysis of surgical samples, and provide a written apology to the woman. The GP has provided the requested information and apology.
The medical centre has since put in place a policy to ensure a consistent approach to management of minor surgery samples, and all tissue samples will now be sent for histological analysis.
The full report on case 19HDC01320 can be found on the HDC website.