Summary
C was diagnosed with a malignant melanoma (a type of skin cancer) and referred to a consultant oral and maxillofacial (the specialty concerned with the diagnosis and treatment of diseases affecting the mouth, jaws, face and neck) surgeon for surgery. A wide local excision (WLE, a surgical procedure to remove a small area of diseased or problematic tissue with a margin of normal tissue) was carried out. C complained that they should have been offered a sentinel lymph node biopsy (SLNB, a procedure in which the sentinel lymph node is identified, removed, and examined to determine whether cancer cells are present) at the same time as the WLE, in accordance with clinical guidelines. C complained that without having had SLNB, their disease could not be accurately staged.
The board said their priority had been the excision and that on review by the surgical team SLNB was not recommended. C received a computer tomography (CT) scan and the report from this was discussed at the appointment attended with the consultant oral and maxillofacial surgeon. The consultant confirmed at the appointment that the pathology report staged C's melanoma at stage 2 (the melanoma is only in the skin and there is no sign that it has spread to lymph nodes or other parts of the body). C also received an ultrasound fine needle aspiration (FNA) of their right neck and biopsy. The board said accuracy of SLNB at this stage was limited and likely to carry more morbidity; therefore they suggested to follow up with six monthly CT scans and consideration of repeat ultrasound at alternate six monthly intervals. In their response to our enquiries, the board acknowledged that C ought to have had a SLNB at the time of their wide excision, providing their general medical fitness was appropriate for general anaesthesia.
We took independent clinical advice from an appropriately qualified adviser. The adviser confirmed that C met the criteria for SNLB to be offered in accordance with Scottish Intercollegiate Guidelines Network (SIGN) and National Institute for Health and Care Excellence (NICE) guidance. While the adviser noted C had an effective operation with no delays, there had been a missed opportunity for SNLB. The adviser considered the impact was hard to see, and that given C's good pathology report, which found no pathological lymph nodes by ultrasound and their internal organs free of melanoma, their prognosis was excellent. The adviser nevertheless considered that C ought to have been given the choice to undergo SNLB at the time of the WLE, and noted the effect on C was that they could not take part in melanoma trials nor could they have confidence in the possibility of being successfully treated. The adviser was critical of the board for not having ratified the guidelines. Taking all of the above into account, we upheld this complaint.
Recommendations
What we asked the organisation to do in this case: Apologise to C for failing to offer a sentinel lymph node biopsy at the time of excising their melanoma, with a recognition of the distress this matter has caused them. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information leaflets.
In their apology letter, the board should explain to C why the guidelines have not been ratified and advise C of their future intentions in this regard.
What we said should change to put things right in future: An action plan should be devised for ratification of the SIGN/NICE guidelines.
The outcome of this complaint should be fed back to relevant staff in a supportive manner.
We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.
Related reading
View Decision Report 202001157 as a PDF (29.52 KB) Updated: March 24, 2021