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Failure to read and convey information in histology report (15HDC00484)
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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
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
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
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
The medical centre was found not to have breached the Code or to
be vicariously liable for the GP's breaches of the Code.