Avoiding diagnostic delays in malignant melanoma

As summer approaches, we provide advice on avoiding missing a diagnosis of skin cancer.

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 thought 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 that 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.

Reasons for complaints and claims

During a recent two year period there were 79 incidents reported to the MDU which involved malignant melanoma. A common factor in these incidents involved a complaint or claim following an allegation of a delayed or missed diagnosis.

A delayed diagnosis may lead to a poorer prognosis with some patients having developed metastases at the time of diagnosis. The findings from the incidents we examined included the following points.

  • Nearly half the incidents (39) were claims for compensation, and 34 of them were complaints. Of those, four were referred to the Parliamentary and Health Service Ombudsman and two to the GMC. The alleged delay in diagnosis from the time the patient presented ranged from three weeks to nearly three years.
  • The age ranges of the patients diagnosed with malignant melanoma ranged from 15 to 85 years.
  • Nearly 80% of cases related to patients seen in general practice (66), with three of those having been seen by a practice nurse or advanced nurse practitioner. Other specialties included dermatologists (7), pathologists (2), a respiratory physician, a prison medical officer, an ENT surgeon and a cosmetic surgeon.
  • Complaints related to pathology were due to a delay in reporting of samples.

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 was 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 whilst 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.

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 of the MDU cases reviewed 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.
  • Take into account 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.

This guidance was correct at publication 14/05/2020. 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.

Dr Kathryn Leask

by Dr Kathryn Leask BSc (Hons) MBChB (Hons) LLB MA MRCPCH FFFLM DMedEth MDU medico-legal adviser

Kathryn has been a medico-legal adviser with the MDU since 2007 and is a team leader, trainer and mentor in the medical advisory department. Before joining the MDU, she worked in paediatrics gaining her MRCPCH in 2002 and did her specialty training in clinical genetics. She has an MA in Health Care Ethics and Law, a Bachelor of Law and a Professional Doctorate in Medical Ethics. She is also a fellow of the Faculty of Forensic and Legal Medicine and has previously been an examiner and Deputy Chief Examiner for the faculty exam. Kathryn is currently a member of the faculty's Training and Education Subcommittee.

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