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Oversights in diagnosis of skin cancer - Health and Disability Commissioner

Fuseworks Media
Fuseworks Media

Health and Disability Commissioner Anthony Hill today released a report finding two general practitioners and a skin clinic in breach of the Code of Health and Disability Services Consumers’ Rights (the Code) for oversights in relation to a man’s diagnosis of skin cancer.

The man sought treatment for a lump on his right ear and about 18 months later sought treatment for a general lump on his neck. The lump was a squamous cell carcinoma (SCC) that had spread from the ear to the man’s lymph nodes. The man received surgery and radiation therapy but sadly he died.

The man’s GP initially overlooked making a referral for surgery and did not inform the man about this oversight.

The man also sought treatment from a GP at a skin clinic (skin clinic GP). That GP did not co-operate with or communicate effectively with the man’s GP, in particular in relation to the details of the man’s SCC diagnosis, and did not provide details of a follow up plan.

The man’s GP subsequently did not pick up on the mention of the man’s SCC history in a letter from the skin clinic GP. This contributed to a delay in the man receiving a specialist appointment and impacted on the GP’s care of the man when he had a high risk diagnosis.

There was a delay in the skin clinic sending the consultation notes and histology report to the man’s GP. This contributed to the GP being unaware of the SCC diagnosis.

Mr Hill noted how important it is for providers who are involved in a consumer’s care to communicate effectively with one another, and to have good systems in place for sharing clinical information. He emphasised the need for providers to review information carefully, and to communicate openly with the consumer.

Mr Hill also recommended that the skin clinic make changes to its processes to ensure that a consumer’s GP be notified when a patient is found to have a lesion of significance at a free skin check, and undertake an audit of 30 skin cancer removal procedures. Mr Hill recommended that both GPs and the skin clinic apologise to the man’s partner, which they have done.

The full report for case 17HDC01829 is available on the HDC website.

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