Melanoma is the second most common cancer in adults aged 25-49.

GPs across the country see many thousands of skin lesions every year, most of which will be benign. But among them will be about 15,000 melanomas requiring accurate and timely diagnosis so that patients can be treated promptly.

A great number of other conditions in general practice require accuracy in diagnosis and early referral, but melanoma is particularly challenging because diagnosis can be difficult.

GPs are particularly vulnerable to facing a claim of this type, because most patients present in primary care.

Timely diagnosis and referral can also avoid the doctor facing a complaint, claim or even disciplinary action and referral to the GMC.

NICE guidelines

In the MDU's experience, the majority of melanoma claims relate to either delay in diagnosis or wrong diagnosis. 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 taken 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.

Reducing claims and complaints

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

Keep practice protocols and staff training on dermatology up to date and in line with national and locally-agreed guidelines.
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.
Make sure any patient consultation about a suspicious skin lesion is clearly documented, including the history taken, the examination performed, the differential diagnosis and the management plan.
Check the patient understands plans for follow-up and that these are also clearly documented.
Where a referral has been made, particularly if it is under the two-week rule, it's advisable to have systems in place to check that an appointment follows, so that no one is lost in the system.
Your practice should also 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.
Have in place a protocol for dealing with test results and administrative tasks, such as dealing with messages to and from patients. Protocols are a helpful statement of the standard of care to be provided and a definition of responsibilities within the team.
Ensure the practice has a robust system, such as a Significant Event Audit, for analysing patient safety incidents. This can highlight lessons that can be learned and what changes should be put in place to prevent a similar situation in the future.
Provide patients with 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.

Avoiding skin cancer diagnosis delays

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