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Case ref:201101586
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Date:February 2012
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Body:Highland NHS Board
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Sector:Health
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Outcome:Some upheld, recommendations
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Subject:clinical treatment / diagnosis
Summary
Mr C attended his GP with regard to a lesion below his right eye. His GP referred him to a clinic at the hospital for further examination of the lesion. He was reviewed by a registrar initially in November 2010, and attended for the procedure around one month later. When Mr C left the clinic, he found the lesion he was concerned about remained on his face, and a lesion on his nose had been removed instead. Mr C complained to the board.
We found that the notes for the initial clinical appointment contained inaccurate details, and that the lesion for which Mr C’s GP had referred him was not the lesion subsequently identified by the registrar for removal. On this basis, we upheld Mr C’s complaint that the board failed to remove the lesion which he had been concerned about. Mr C had several lesions on his face, and it may also have been helpful if the original GP referral had included details of the other lesions to prevent this confusion arising.
However, we did not uphold Mr C’s second complaint that it was inappropriate to remove the lesion from the side of his nose. Examination of this lesion established that it was a benign tumour and, therefore, it was of clinical concern and certainly the most high risk lesion on Mr C’s face. We also found Mr C had signed a consent form prior to the procedure which stated he consented to any additional procedure which was in his best interests and justifiable for medical reasons.
We did not uphold Mr C’s third complaint that he had been provided with conflicting information regarding the necessity of removing the lesion he had been concerned about. The board had referred Mr C on to a dermatology specialist who had established this lesion was a mole which could be treated satisfactorily with cryotherapy. We did not find this to be conflicting, but in fact appropriate medical advice on the best way in which to proceed.
Recommendation
We recommended that the board:
• apologise Mr C for removing a different lesion on his face to the one he and his GP were concerned about.