Decision Report 201204779

Summary

A Member of Parliament (Mr C) complained to us on behalf of Mr and Mrs A whose daughter (Ms A) died from skin cancer. Mr and Mrs A felt that their daughter's diagnosis and treatment was unreasonably delayed because a mole was not properly removed from her scalp four years previously, and that there was a failure to make appropriate follow-up arrangements. They also said that the board refused Ms A’s requests for surgery when she developed a breast lump and unreasonably insisted that she attend an appointment at a time when bad weather made travelling to hospital very difficult.

As part of our investigation, we took independent advice from two medical advisers, a skin specialist and a cancer specialist. Our investigation found that Ms A’s mole was at first only partially removed because of where it was on her scalp. A biopsy (tissue sample) was taken and analysed, and it was reported that the results did not show that the mole was malignant. Based on this, it was reasonable that there was no formal follow-up after the mole was removed. However, our investigation found that histopathology reporting (the study of changes in tissues caused by disease) was unsatisfactory, as the biopsy was reported incorrectly and the sample taken did show signs of malignancy. One of the advisers also said that it would have been good practice to remove the mole fully, as it was clearly possible to have done so. Ms A then developed lumps on her neck and, later, a lump on her breast. Although we found that the board carried out appropriate investigations into these lumps and provided relevant treatment, we found that there had been some avoidable delays because Ms A was not prioritised as a suspected cancer patient. We upheld Mr C's complaints about removal of the mole and about diagnosis.

We did not uphold the complaints about the appointment, or about refusal to offer surgery earlier. We found that three separate tests had found that Ms A’s breast lump was benign and skin cancer in the breast of a woman of her age would be very rare. As such, we were satisfied that the board’s initial advice that surgery was not necessary was reasonable. Surgery was arranged appropriately when the lump persisted and began to irritate Ms A. We were also satisfied that the board did not insist that Ms A attend her appointment during the difficult weather conditions. They did give appropriate advice about how long it might take to reschedule the appointment, should she decide not to attend.

Recommendations

We recommended that the board:

• apologise to Mr and Mrs A for their failure to remove all of Ms A's mole and for the incorrectly reported biopsy;
• review their systems for clinical pathological correlation with a view to avoiding a similar misdiagnosis in the future;
• apologise to Mr and Mrs A for the delay to Ms A's diagnosis; and
• conduct a review within their breast, radiology and pathology departments of their sampling techniques and histopathology reporting quality.