Following guidelines

A female patient asked a newly qualified GP to check a mole on her leg that had bled after she had caught it shaving. The patient revealed that she used to be a regular user of tanning salons, but had stopped after her aunt was diagnosed with skin cancer.

The GP, who had recently started at his first practice, carefully examined the mole and reassured the patient that it was almost certainly benign. He advised the patient to keep an eye on it and return if it changed size, shape or colour.

A month later, the patient returned to say that the mole was itching and had become inflamed. The GP made an urgent referral to the fast-track dermatology clinic where it was removed and sent for analysis. This revealed the patient had a malignant melanoma which required wide local excision, although further tests fortunately showed that the cancer had not metastasised.

The GP looked back on his notes with the practice owner, which established that he had not followed the checklist for assessing skin lesions as recommended by NICE. To address this gap in his knowledge, he enrolled in professional development courses on the diagnosis and referral pathway for melanoma. He also completed a piece of reflective writing about the value of national guidelines.

However, the GP was dismayed to find himself the subject of a series of different investigations into his error. This began with a complaint from the patient, who said the GP should have made an urgent referral at her first appointment. She also reported him to the GMC, which began an investigation. The GMC notified the case to NHS England, which then asked the local performers advisory group (PAG) to consider whether any action needed to be taken on the GP’s inclusion on the Performer’s List. The GP was invited to submit comments.

In its response to the complaint, the practice included an apology from the GP and reported what he was doing to learn from the incident. The practice also explained it was implementing its own protocol for suspected skin cancer to ensure they were fully in line with national guidelines. The patient did not take her complaint further but later moved to another practice.

The GMC was critical of the GP’s failure to follow the relevant NICE guidance. However, it also noted this was a single incident and in the light of the GP’s efforts to remediate, it concluded the case with a letter of advice. After being informed of the outcome of the GMC’s investigation, the PAG allowed the GP to continue on the Performer’s List.

MDU advice

• While guidelines do not replace the knowledge and skills of GPs, you are expected to be familiar with any nationally recognised guidelines and take them into account when exercising your clinical judgment.
• A GP may be subject to many investigations arising from a single clinical incident – patient complaint, disciplinary inquiry, GMC complaint, claim for negligence and even a police investigation. We call this multiple jeopardy.

Our members can call on us for assistance before a trial, fitness to practise panel or coroner’s inquest/FAI, and get help to prepare statements and arrange legal representation if needed.