Several months after suffering a crush injury to his left hand at work, a 40 year old patient had a split nail on his left thumb, which seemed to be "festering". He visited his GP who prescribed antibiotics and told the patient to come back if his condition did not improve.
Two years later, his thumb was swollen and the nail bed deformed with no nail visible. The patient saw another GP at the practice. He was referred to a plastic surgeon and a biopsy was performed. Histology was reported as a pleomorphic spindle cell tumour with a high mitotic rate, which had the appearance of a fibrosarcoma. It was agreed to amputate the thumb and, after this operation, the resection margins were found to be free of tumour.
The patient was admitted to hospital three years later, after he hit the stump with a hammer. He was treated with intravenous antibiotics for cellulitis of the dorsum of the right hand which extended to the forearm.He also had palpable lymph nodes in the axilla and was referred for a block dissection. A biopsy revealed a malignant spindle cell melanoma. A CT scan revealed multiple lung secondaries. The patient had chemotherapy, but died within a year.
The patient's wife alleged that the first GP had been negligent in managing what proved to be an amelanotic melanoma under the thumb nail. It was alleged that she had failed to take a proper medical history or make an appropriate referral, and failed to review matters after prescribing the course of antibiotics. She claimed that the GP's failure to diagnose a melanoma had resulted, on the balance of probability, in a failure to prevent her husband's death.
The MDU consulted several experts, who all agreed that the case should be defended. It was pointed out that malignant melanomas are rare and that less than three percent of these are subungual. They also commented that subungual melanomas frequently masquerade as a much more common benign condition. The GP had advised the patient to return if the condition did not settle after a course of antibiotics for what appeared to be a simple post-traumatic infection. The patient had failed to reattend.
An expert plastic surgeon said that, even if the initial lesion had been a subungual melanoma and not just an infected split nail, there were signs of inflammation and it is almost certain that such a melanoma was already ulcerated. This, along with the fact that it was amelanotic, would give the patient a poor prognosis in any case:
"With the benefit of retrospection, it is reasonable to say that this particular tumour, by its subsequent behaviour, has demonstrated that it was in the high risk, low survival category from the outset and that therefore any alleged delay in diagnosis and treatment has made little or no difference to the ultimate fatal outcome."
The experts believed the GP had a strong case for going to trial, but she was unwell and unable to attend court. With her agreement the MDU's lawyers reached an out-of-court settlement without admitting liability.
This guidance was correct at publication 04/01/2004. It is intended as general guidance for members only. If you are a member and need specific advice relating to your own circumstances, please contact one of our advisers.