Gregor Lynn

Dear Ms Jones Re: Regulation 28 Report to Prevent Future Deaths – Gregor Patrick Edward Lynn Thank you for your Regulation 28 Report dated 18th December 2023 concerning the death of Gregor Patrick Edward Lynn who died on 8th July 2022. Firstly, we would like to express our sincere condolences to the family. We have taken this matter extremely seriously. The Regulation 28 Report concludes that Mr Lynn’s death resulted from disseminated metastatic melanoma. Following the inquest you raised concerns in your Regulation 28 Report that patients who have lesions excised privately do not always have the histological analysis which would be provided on the NHS as standard practice in primary care. Unfortunately, NHS Cambridgeshire and Peterborough Integrated Care Board has no influence over the pricing structure, or the optionality of histology, offered by private providers that deliver non-NHS funded treatment within our geographical area. However, to ensure that we do all we can to learn from Mr Lynn’s death and improve care for future patients we have used the information you provided to consider other related safety aspects. We understand from the Prevention of Future Death Notice that the lesion when initially reviewed in 2019 was considered benign, so we have reviewed both our current referral policies for benign skin lesions and our previous version that was in place at the time. 6

Our current benign skin lesion policy states that whenever there is diagnostic uncertainty or there is suspicion of malignancy the benign skin policy should not be used as the patient should be referred onto the relevant NHS provider. As a result of receiving your Regulation 28 Notice we are taking the following actions:
• Signposting all GPs working for the NHS within NHS Cambridgeshire and Peterborough Integrated Care System to guidance on detection of skin cancers.
• Reminding all the GPs working for the NHS within NHS Cambridgeshire and Peterborough Integrated Care System that for any skin lesions where there is diagnostic uncertainty, or if there are concerns of malignancy, appropriate onward referral should occur and the benign skin policy should not be used.
• Reminding all services that we commission in primary care that when any skin lesions are excised in primary care they should be sent routinely for histology. Thank you for bringing this important patient safety issue to our attention. Please do not hesitate to contact us should you need any further information.

Dear Coroner, Re: Regulation 28 Report to Prevent Future Deaths – Gregor Patrick Edward Lynn who died on 8 July 2022. Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 20 December 2023 concerning the death of Gregor Patrick Edward Lynn on 8 July 2022. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Gregor’s family and loved ones. NHS England are keen to assure the family and the coroner that the concerns raised about Gregor’s care have been listened to and reflected upon. Your Report raised the concern that there is a risk of future deaths if patients opt out of paying for histological analysis or further tests when being treated privately because they have not met NHS criteria referral. As you have outlined in your Report, the GP who undertook the excision in this case was doing so on a private patient basis. NHS England and NHS commissioners are not able to influence how private care is delivered to patients. I note that you have also sent your Report to the Department of Health and Social Care. You may also wish to refer this case to the Care Quality Commission (CQC) who are responsible for ensuring that standards of quality and safety are upheld within private hospitals and clinics. Regarding the initial management of an evolving, changing lesion within a primary care setting, the National Institute for Health and Care Excellence (NICE) guidelines for Suspected cancer: recognition and referral (NG12) cover the identification of children, young people and adults with symptoms that could be caused by cancer and the appropriate investigations within primary care settings. Cancer Specialists at NHS England have been consulted on this case and have advised that it would have been reasonable for an NHS referral to be made in this case, given the size of the lesion and the apparently irregular features and that any changing lesion, where a definitive diagnosis has not been made, should be considered for a referral to secondary care. NICE issued a document titled ‘Scenario: ‘Referral for suspected skin cancer’, first published in 2000, and subject to a minor update in 2016, which states: 8

"Discussion with a specialist (for example, by telephone or email) should be considered if there is uncertainty about the interpretation of symptoms and signs, and whether a referral is needed. This may also enable the primary healthcare professional to communicate their concerns and a sense of urgency to secondary healthcare professionals when symptoms are not classical." The Academy of the Medical Royal Colleges (AoMRC) have also a produced a document on the optimum management of benign skin lesions:

This states that ‘Any lesion where there is diagnostic uncertainty, pre-malignant lesions (actinic keratoses, Bowen disease) or lesions with pre-malignant potential should be referred or, where appropriate, treated in primary care.' In addition, NHS England notes from the GP statement given to the coroner inquiry the additional information that the lesion had been noted to bleed. Thus, it would appear to meet the criteria for NHS referral to a dermatologist. As stated above, NHS England is not able to comment on the care provided to Gregor within a private health setting. However, the standard of care for any changing lesion would, in most cases, be to get histological confirmation of its nature and this should have been recommended to the patient. We note from the GP’s statement that they state they would have done so. NHS England have also engaged with Cambridgeshire and Peterborough Integrated Care System (ICS), formerly the Clinical Commissioning Group (CCG) in this matter, on the concerns raised in your Report and any system and local learnings that have been taken. They have advised that they have reviewed their policy for benign skin lesions which states that if there is any diagnostic uncertainty as to whether a lesion is benign, or any possibility that it could be malignant, the policy should not be used, and an appropriate referral made. The ICS have advised that they have:
• Reminded all GPs within Cambridgeshire and Peterborough Integrated Care System of the guidance on skin cancers.
• Shared the benign skin lesion policy to the GPs within Cambridgeshire and Peterborough Integrated Care System such that clinicians are cognisant that in all cases of diagnostic uncertainty or if there are concerns of malignancy onward referral should occur.
• Reminded their NHS primary care commissioned dermatology services of the guidance on techniques and facilities for conducting minor surgery and relevant best practise guidance, including that all tissue removed by minor surgery should be sent routinely for histological examination unless there are exceptional reasons for not doing so.
• Initiated discussions with the British Association of Dermatology and NHS England colleagues to ensure that there is learning and exploration of national management guidance which includes skin cancer. I would also like to provide further assurances on national NHS England work taking place around the Reports to Prevent Future Deaths. All reports received are discussed 9

by the Regulation 28 Working Group, comprising Regional Medical Directors, and other clinical and quality colleagues from across the regions. This ensures that key learnings and insights around preventable deaths are shared across the NHS at both a national and regional level and helps us pay close attention to any emerging trends that may require further review and action. Thank you for bringing these important patient safety issues to my attention and please do not hesitate to contact me should you need any further information.