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.