• Case ref:
  • Date:
    January 2019
  • Body:
    Ayrshire and Arran NHS Board
  • Sector(s):
  • Subject:
    clinical treatment / diagnosis
  • Outcome:
    Upheld, recommendations


Mrs C complained about the care and treatment that was provided to her at University Hospital Crosshouse for a melanoma in situ (an early stage of skin cancer where the cancer cells are in the top layer of skin) on her face. Mrs C was concerned that the consent process for the procedure to remove the melanoma was inadequate, as she had been unaware that she would be left with a scar far larger than the area of skin removed. Mrs C complained about the procedure that was carried out and considered that the overall handling of her complaint was unreasonable.

We took independent advice from a consultant maxillofacial surgeon (a doctor who specialises in treating diseases and injuries to the mouth, jaws, face and neck). We found that the procedure carried out to remove the melanoma in situ was appropriate for Mrs C and there were no concerns about the standard of the surgery itself. However, we found that the consent process had been inadequate and that the operation note was not sufficiently detailed. Neither of these records included a diagram to aid understanding of the procedure, and there was no evidence that the extent of the wound Mrs C would be left with had been discussed before the surgery. The advice also highlighted that, despite the fact that the melanoma in situ was in a cosmetically sensitive area on Mrs C's face, no photographs were taken prior to initial investigations. We upheld Mrs C's complaint about care and treatment.

In relation to complaints handling, we found that the board had not responded within the 20 working day target and that Mrs C had not been kept timeously updated. We upheld this complaint.


What we asked the organisation to do in this case:

  • Apologise to Mrs C for the inadequate consent process, the quality of the operation note and the complaints handling failing identified. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.

What we said should change to put things right in future:

  • There should be effective communication with patients to ensure they have sufficient information to understand their treatment. The consent process should be in line with national guidance on consent.
  • Consideration should be given to photographing all pigmented lesions or lesions of cosmetic significance prior to biopsy.
  • Operation notes should be of an appropriate standard.

In relation to complaints handling, we recommended:

  • Complaints should be handled within the prescribed timescale and where this is not possible, complainants should receive a timeous update.