Melanoma is the fifth most common cancer in the UK with approximately 16,000 people being diagnosed each year. According to Cancer Research UK it is believed that 86% of cases are preventable.

Additionally, while the incidence of melanoma increases with age, Melanoma UK reports that the number of cases in young people is disproportionately high, making it one of the most common cancers in people aged 15 to 37.

Patients will generally present to primary care if they notice a concerning or unusual skin lesion. Therefore, it is particularly important GPs are confident in assessing and making management decisions about skin lesions. Melanoma is a particularly challenging diagnosis to make as skin lesions can be variable and can initially appear benign.

Delayed diagnosis

Failure to diagnose malignant melanoma is not necessarily negligent. However, a claim may succeed if it is possible to demonstrate a doctor's management fell below the expected standard.

An example might be if a patient had typical signs and symptoms and the doctor did not actively consider the possibility of a melanoma, or failed to carry out an appropriate assessment of them.

It can be difficult to differentiate melanoma from other skin lesions and NICE recommends a weighted seven-point checklist. If melanoma is suspected, or where the nature of the lesion is uncertain, NICE recommends a two-week wait referral for biopsy by a specialist.

Any skin lesion excised in primary care should be removed with a margin and sent for pathological examination with appropriate clinical details.

It's important to remember that melanomas can arise on all parts of the body, even in rare sites such as ophthalmic or subungual tumours. One MDU case involved a subungual melanoma where the delay in diagnosis resulted in the amputation of a digit.

To help reduce the risk of delayed and missed melanoma diagnosis, we advise the following:

Communicating with patients

Check the patient understands plans for follow-up and that these are also clearly documented.
Consider a patient's past history of malignant melanoma if they later present with non-specific symptoms such as pain or fatigue. Consider whether this could be a recurrence and possible metastases.
If a referral has been made, particularly if it is under the two-week rule, it's advisable to have systems in place to check an appointment follows, so the referral isn't lost in the system.
Make sure a consultation about a suspicious skin lesion is clearly documented, including the history taken, the examination performed, the differential diagnosis and the management plan.

Protocols and training

Keep protocols and staff training on dermatology up to date and in line with national and locally-agreed guidelines. Protocols are a helpful statement of the expected standard of care to be provided and a definition of responsibilities within the team.
Actively consider whether you need further training in the diagnosis and referral pathway for melanoma, and whether this should be included in your personal development plan and appraisal.
In general practice, it's important to have a safe system for following up test results, including a process for responding to abnormal results and making sure these are communicated to patients.
Likewise, with test results and administrative tasks, ensure your protocol includes how messages to and from patients are dealt with and any timescales.

Responding to an incident

Ensure the practice has a robust system for analysing patient safety incidents, such as a significant event audit. This can highlight what lessons can be learned and what changes should be put in place to prevent a similar situation in the future.
Give patients an explanation and apology if something does go wrong, particularly if the outcome is poor or unexpected.
Take steps to deal with the consequences and arrange appropriate treatment and follow-up.
Contact the MDU at the earliest opportunity if you have any concerns.

Recording advice

Successfully defended claims included those where the doctor had clearly documented their examination findings confirming that, at the time of the consultation, no features of malignancy existed. Another feature of these cases is that the advice provided was documented, such as asking the patient to self-monitor the lesion and return urgently if they had concerns.

Recommendations could include the patient taking a photograph of the lesion so they have a comparison and measuring the lesion to see if there is any change in size. Other symptoms/ signs the patient has been advised to watch out for should also be documented.

Where a routine referral is indicated, it is important to ensure the patient understands that they must return if there is any change in the skin lesion while they are awaiting the appointment. This is especially the case if the date of the appointment is some time in the future.

Some delays arose where a referral had been made but there had been a failure in the system with the patient not receiving an appointment or where a biopsy had been taken but there was a delay in the GP receiving the result. It is therefore important that systems and policies are in place to ensure that results have been received in a timely manner.

Avoiding diagnostic delays in malignant melanoma

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