A practice in the Doncaster area

4. Miss I complains about aspects of the care and treatment she received at the Practice. She complains:

• the Practice failed to investigate her skin lesions appropriately • the Practice should have offered an urgent face-to-face appointment with dermatology in March 2024 and the treatment plan made based on photos was inadequate as she had to go private to have the lesions removed.

5. As a result, Miss I says she had a large scar on her back from March, and a smaller one on her face which could have been avoided. She is now conscious about the scar on her face. Miss I says the consequences of the Practice’s failures have affected her mentally and physically.

6. By bringing her complaint to us, Miss I wants service improvements.

7. Miss I was seen by the Practice since 2011 for her skin problems.

8. Miss I’s appointment on 31 March 2022 at the Practice was concerning two patches of eczematous looking skin on both cheeks. She was asked to continue with a moisturiser and call back if she wasn’t better in two weeks.

9. Miss I was next seen by a physician associate on 31 May 2023 regarding shoulder pain. While the physician was examining her right shoulder, she noticed an eczematous patch of skin on the back of Miss I’s neck. She informed the physician it felt inflamed and itchy. A mild steroid cream was offered to apply topically to the area which she had used previously in 2018 for a similar skin problem. Miss I was safety netted and advised to call the surgery if the patch worsened in any way.

10. She was then seen regarding her skin issue on 20 February 2024. The consultation noted Miss I was seen two weeks ago at the Same Day Health Centre for eczema as a presenting complaint. She informed the doctor she had been prescribed hydrocortisone cream (steroid cream) but had read it shouldn’t be applied to broken skin.

11. The doctor advised Miss I to send some photos, and they would ask dermatology for their opinion. The Practice received a response from dermatology on 4 March which advised it was a superficial basal cell carcinoma (BCC). BCC is a type of skin cancer which is normally very slow growing.

12. Dermatology asked the doctor to prescribe imiquimod 5% cream (skin treatment), which was to be used five times per week (Monday to Friday) for six weeks.

13. The dermatology department also advised imiquimod can cause local inflammation, and advised Miss Nicholson should have the lesion reassessed in three months. Miss I was contacted on 5 March by the Practice to make an appointment to discuss dermatology’s advice.

14. On 6 March, Miss I had a face-to-face appointment with one of the doctors. They advised the lesions had been reviewed by dermatology. The doctors also informed Miss I about the diagnosis of superficial BCC, the proposed treatment plan, and for a further review in three months. The recommended cream was prescribed to Miss I.

15. Miss I wanted to obtain private opinion to have the lesion surgically removed, and a referral letter was made by the doctor.

16. She had the lesion removed from her upper back privately around March 2024, which left her with nine-centimeter (cm) stitches. She also had the lesion removed from her left jaw line.

Inadequate investigations

20. Miss I complains she was prescribed creams but did not have her skin concerns investigated. She says the creams had not resolved her skin issues in the past. She questions how it is possible to get eczema and skin cancer muddled up, and why the doctor was happy to prescribe a cream without investigating the lesions via dermatology.

21. Miss I also questions in her complaint why it has taken this long to have her concerns about her skin queried and investigated.

22. The Practice responded to Miss I’s concerns with a chronology of appointments dating back to 2011. It referred to the characteristics of BCC which were not usual during her consultation on 31 March 2022. The doctor noted two patches on Miss I’s face which were the size of a 10 pence coin.

23. It said the likely diagnosis was eczema due to the patches appearing and disappearing intermittently, and the skin looked dry. The diagnosis of BCC is difficult due to the slow growing nature of the lesions, and most lesions are reported as never fully healing with either bleeding or producing a scab from time to time.

24. The Practice said from Miss I’s history, it appeared unlikely to be BCC and to treat it as eczema. The doctor never saw Miss I again for the lesions, if they did, they would have referred to her dermatology if the lesions did not respond to the treatment given.

25. BCC is a type of skin cancer which is normally very slow growing, and NHS England notes it as the most common type of skin cancer.

26. NICE CKS Skin cancers – recognition and referral, say, ‘consider routine referral for people if they have a skin lesion that raises the suspicion of a basal cell carcinoma.’

27. It also recommends ‘only consider a suspected cancer pathway referral (for an appointment within 2 weeks) for people with a skin lesion that raises the suspicion of a [BCC] if there is particular concern that a delay may have a significant impact, because of factors such as lesion site or size.’

28. Our adviser says BCC is not usually viewed as a threat to life, and not even included in some two week wait referrals to dermatology as recommended by NICE.

29. In Miss I’s case, evidence shows on 31 March 2022, she presented to the practice with two patches on her cheek which were intermittent and described as ‘eczematous looking skin on both cheeks’. The consultation advised Miss I to carry on with moisturisers, and to return if she was not better after two weeks which Miss I did not do.

30. Our adviser says the advice given on 31 March appears to be appropriate management as there is no clear suggestion her symptoms could be BCC. Our adviser also explains the latter would not normally resolve and reappear like eczema would do. As a slow growing cancer, the skin lesion would persist and grow slowly with time.

31. Miss I was also safety netted to come back if her issues were not resolving. The actions of the GP are recommended by the BMJ Safety-netting in the consultation, which says safety netting can help mitigate the risk for patients with serious underlying conditions.

32. We do not think anything went wrong during the consultation of 31 March, and we find Miss I was appropriately reviewed in line with NICE CKS Skin cancers and BMJ safety netting.

33. Miss I was seen by a physician associate mainly for shoulder pain on 31 May 2023 where it was noted she had an eczematous patch on the back of her neck which felt inflamed and itchy. The records show a mild steroid cream had been helpful in the past and it was prescribed again.

34. NICE Eczema - atopic: NICE stepped approach to treatment, identifies how treatment can be stepped up or down according to the severity of atopic eczema. It says, ‘treatment of a flare will often require temporarily ‘upping’ the intensity of treatment, (for example, the strength of corticosteroids)’.

35. Like the appointment of 31 March 2022, our adviser says Miss I was appropriately safety-netted to contact the Practice if her symptoms were not settling, and the management during the consultation was reasonable according to NICE Eczema guidance.

36. We considered the next consultation which was on 20 February 2024. The GP now felt the skin lesions may not be eczema. The consultation notes for the first time the lesion on the back of the neck had started to bleed, and it looked raised and irregular. The GP then asked dermatology for a second opinion.

37. Our adviser says the actions of the GP were appropriate as they obtained a second opinion but did not feel it was a more aggressive form of skin cancer such as melanoma or squamous cell carcinoma (SCC). These types of skin cancer would require a two week wait as noted in NICE CKS Skin cancers – recognition and referral.

38. BAD Basal cell carcinoma, describes what it can look like and how people can identify this type of cancer. It states ‘people often first become aware of them as a scab that bleeds and does not heal completely or a new red or pearly lump on the skin. Some BCCs… look like a scaly red flat mark on the skin.’

39. As established above, it can present with a scab that does not heal completely rather than resolve and then come back. In addition, some look like ‘scaly, red flat mark on the skin’ and the Skin Cancer Foundation notes in Basal Cell Carcinoma Warning Signs, BCCs resemble noncancerous skin conditions such as psoriasis or eczema.

40. We recognise Miss I was frustrated especially when she had to reattend the GP Practice for a reoccurring skin problem, which turned out to be skin cancer. We do not underestimate Miss I’s distress due to her BCC diagnosis. We find the Practice took the appropriate steps to manage her symptoms in line with guidance during her appointments from 2022 onwards.

Dermatology and treatment plan

41. Miss I says she was prescribed a cream by the GP following the dermatology advice. She feels she should have had a face-to-face appointment with dermatology which would have investigated the nature of her lesions and known it required a surgical removal.

42. She believes the treatment plan made based on photos was inadequate as she had the lesions removed surgically.

43. The Practice said the doctor advised Miss I to send some photos for dermatology opinion, and the response received on 4 March advised the lesion was a superficial BCC. It advised the doctor to prescribe imiquimod 5% cream, and this was prescribed as recommended. The doctor recalled Miss I advising him she wished to seek private opinion, and a referral letter was prepared.

44. NHS England has outlined the benefits of teledermatology in A teledermatology roadmap: implementing safe and effective teledermatology triage pathways and processes.

45. It explains teledermatology as the usage of digital images to triage, diagnose, monitor or assess skin conditions without the patient being physically present.

46. NHS England states in its principle of 1.1 the following:

‘The use of specialist advice and guidance (A&G) supported by images, including dermoscopic images for skin lesions, with the option of conversion to a referral, is therefore recommended as the ‘front door’ to all dermatology services, including for people with rashes, except urgent suspected skin cancer referrals (previously known as the 2-week wait skin cancer pathway).’

47. ‘Faster diagnostic pathways Implementing a timed skin cancer diagnostic pathway Guidance for local health and care systems’ by NHS England and BAD explains ‘…[BCC] is usually locally malignant and unlikely to spread to other areas. The treatment of people with this cancer sits outside the cancer waiting times (CWT) guidance.’ As such, in normal cases BCC would not be viewed as an urgent requirement for a referral.

48. Our adviser explains the actions of the GP were appropriate, because sending photos to the dermatologist can provide a much quicker assessment rather than awaiting a face-to-face appointment which can take a long time. In this case, our adviser says the diagnosis of BCC was made swiftly and prompt treatment was advised.

49. We also considered whether the GP should have offered any surgical removal other than the cream offered to Mrs I.

50. Our adviser explains once the photos have been reviewed by the dermatologist, it is up to them what management is proposed. Our adviser also says, it is not up to the GP to refer for surgery or any other treatment. Normally, the dermatologist would advise on whether to offer a face-to-face appointment for the patient. A dermatology opinion can be sought to know whether the cream or a referral for surgery was appropriate at this stage.

51. The actions of the GP are in line with GMC guidelines which say:

‘You must provide a good standard of practice and care. If you assess, diagnose or treat patients, you must:

• adequately assess the patient’s conditions, taking account of their history (including the symptoms and psychological, spiritual, social and cultural factors), their views and values; where necessary, examine the patient

• promptly provide or arrange suitable advice, investigations, or treatment where necessary

• refer a patient to another practitioner when this serves the patient’s needs.’.

52. As such, we do not find anything went wrong with the way the GP considered the information provided by the dermatology.

53. We recognise this has been a difficult time for Miss I, and we understand how she has been impacted mentally and physically by the diagnosis of BCC, and the surgical removal of this which led to significant scarring. We can see the GP acted in line with guidance, and we cannot see anything went wrong here.

54. We would like to reassure Miss I again we have looked at her complaint independently and impartially. We thank Mrs I for bringing her complaint to us.

1. We have carefully considered Miss I’s complaint about a practice in the Doncaster ares (the Practice) and we thank Miss I for her patience during this time. We understand why Miss I feels so strongly about this complaint and we recognise how difficult it was for her during this time, especially coping with the medical treatment, and having to submit a complaint shortly after about her experience. We understand the impact scars can have on a person’s confidence and wellbeing. We thank Miss I for bringing her complaint to us and we have considered her complaint in detail with the full information below.

2. We found the Practice followed national guidance during Miss I’s GP consultations. We also found the Practice took appropriate action when seeking further advice from dermatology and taking action upon the advice.

3. We understand our decision will be disappointing for Miss I. We would like to reassure Miss I we have looked at her complaint independently and impartially with advice sought from an experienced clinician.