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Case ref:201707707
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Date:March 2019
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Body:Greater Glasgow and Clyde NHS Board - Acute Services Division
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Sector:Health
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Outcome:Upheld, recommendations
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Subject:clinical treatment / diagnosis
Summary
Mr C complained about the board's treatment of his Basal Cell Carcinoma (BCC, a type of skin cancer). Having undergone three initial operations to remove a BCC, he required a further operation to remove a recurrence around nine years later. Mr C complained that the board failed to treat him properly when they initially carried out the surgery.
We took independent advice from a consultant dermatologist (a doctor who specialises in the diagnosis and treatment of skin disorders).
We found that the pathology report of the third procedure should have raised concerns that the tumour may recur. We noted that Mr C had been offered a follow-up appointment, but did not seem to have been warned of the possibility of recurrence. We considered that reasonable treatment options following the pathology from the third procedure would have included consideration for Moh's surgery (surgery where thin layers of cancer-containing skin are progressively removed and examined until only cancer-free tissue remains) and/or follow-up in one to two years with the warning that the tumour could return.
The board confirmed that following the third procedure, Mr C was reviewed then discharged to his GP two months later. We found that there was no record on file that he was advised the tumour may return. There was also no record of the board having considered treatment with Moh's microsurgery, although they confirmed that it was available at the time in question. Therefore, we upheld Mr C's complaint.
Although we upheld the complaint, we noted the board's comments that had they provided a longer follow-up over two years, this would not have detected or prevented the later occurrence of the BCC. We accepted that it was unlikely this would have detected the recurrence. We also noted that there was no evidence that the surgeries were carried out incorrectly or that they contributed to the recurrence.
Recommendations
What we asked the organisation to do in this case:
- Apologise to Mr C for the failure to consider possible Moh's microsurgery treatment, to arrange an appropriate timeframe for follow-up and to advise of the risk of recurrence of the tumour. The apology should meet the standards set out inthe SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.