Decision Report 202410341

Summary

C complained about the care and treatment provided by the board in relation to a cancerous lesion (squamous cell carcinoma, SCC) on their middle finger. C received cryotherapy for eight months but at the end of the treatment, the lesion was worse. C said that they should have been reviewed by a consultant sooner when it became apparent the treatment was unsuccessful and they would have chosen surgery at the outset if they had been told of alternative treatment options. As a result of the failings, C said that they developed a more serious lesion.

We took independent advice from a consultant in dermatology. We found that the standard of medical care provided was not reasonable in that the uncertainty of diagnosis was not communicated to C and treatment options were not fully considered and discussed. Additionally, cryotherapy treatment was continued without consultant review for an extended period and the GP’s re-referral of C was downgraded to ‘routine’. We upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/meaningful-apologies.

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

• There should be careful discussion of options in the light of equivocal histology reports. This is typically a multidisciplinary team meeting (MDT). Diagnostic uncertainty or limitations should be shared with patients as part of a full discussion of treatment options.
• It is good practice for images to be incorporated into the patient record in the patient lesion pathway.
• There should be closer supervision of the nurse-led cryotherapy service.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.