Summary
C complained about the care and treatment provided by the board in relation to a cancerous lesion (squamous cell carcinoma, SCC) on their middle finger. C received cryotherapy for eight months but at the end of the treatment, the lesion was worse. C said that they should have been reviewed by a consultant sooner when it became apparent the treatment was unsuccessful and they would have chosen surgery at the outset if they had been told of alternative treatment options. As a result of the failings, C said that they developed a more serious lesion.
We took independent advice from a consultant in dermatology. We found that the standard of medical care provided was not reasonable in that the uncertainty of diagnosis was not communicated to C and treatment options were not fully considered and discussed. Additionally, cryotherapy treatment was continued without consultant review for an extended period and the GP’s re-referral of C was downgraded to ‘routine’. We upheld the complaint.
Recommendations
What we asked the organisation to do in this case: Apologise to C for the failings identified. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/meaningful-apologies.
What we said should change to put things right in future: There should be careful discussion of options in the light of equivocal histology reports. This is typically a multidisciplinary team meeting (MDT). Diagnostic uncertainty or limitations should be shared with patients as part of a full discussion of treatment options.
It is good practice for images to be incorporated into the patient record in the patient lesion pathway.
There should be closer supervision of the nurse-led cryotherapy service.
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 202410341 as a PDF (27.54 KB) Updated: May 20, 2026