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Failure to read and convey information in histology report (15HDC00484)

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(15HDC00484, 4 May 2016)

General practitioner ~ Medical centre ~ Histology report ~ Skin lesion ~ Rights 6(1)(f), 4(1)

A man consulted his general practitioner (GP) about a scalp lesion. The GP excised the lesion and sent the lesion specimen for examination. The man was told that if he heard nothing, "all was well".

The GP received a two-page histology report, which stated that the lesion had features consistent with a keratoacanthoma, and that because of the lesion's similarity with squamous cell carcinoma (SCC) and incomplete excision at the deep margin, "follow up" was advisable. The GP saw the diagnosis of keratoacanthoma and, as he regarded it as normal, did not pass it on to the man. He did not read the advice to follow up. The GP concluded that a further biopsy was not required at that time. He saved the report to the man's file and did not make a file note. The GP did not tell the consumer the results or provide any follow-up advice, despite the man having been told that he would be contacted again if follow-up was necessary.

During the following months the man returned to the medical centre for wound review and suture removal by registered nurses. The pathology was not discussed with him. It was the medical centre's policy that nursing staff did not discuss pathology with patients.

Later that year and onwards, the man consulted staff at the medical centre for lesions on his ears, lip, left leg and hands. The results of the biopsies in each case were given to him at the time of suture removal. The consumer did not mention any recurrence of the scalp lesion at these appointments.

The man's scalp lesion reappeared about a year later, and he decided to see a specialist. A further biopsy was taken and sent to histology. The new report was positive for SCC, and the consumer was advised that urgent surgery was required.

The information contained in the histology report was information that a reasonable consumer in the man's circumstances would expect to receive. By failing to provide him with that information, the GP breached Right 6(1)(f). In addition, the GP failed to provide services with reasonable care and skill by not reading the histology report properly and not arranging the follow-up care that had been recommended, and breached Right 4(1).

The medical centre was found not to have breached the Code or to be vicariously liable for the GP's breaches of the Code.

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