A man in his 50s has died after two doctors failed to communicate with each other about his cancer, the Health and Disability Commissioner has found.

Commissioner Anthony Hill has found that the man's general practitioner (GP) forgot to refer him to a specialist after he saw her for a painful lump on his ear on June 20, 2015.

After no communication for three months, he went to a private skin clinic on September 10 where the lump was identified as "an obvious skin cancer".

The skin clinic removed the cancer on September 29, but failed to send a report to the man's GP until the man came back for a follow-up appointment on April 14, 2016. Two months later it sent the GP a discharge summary recording the man's skin cancer history as "nil".


His GP said she concluded that the lump must have been "benign", so she was not alarmed when the man returned on January 25, 2017, this time with a lump on his neck behind the same ear where the cancer first appeared.

She did not take a biopsy of the new lump, but referred the man for blood tests and asked him to come back in a month.

On March 23, 2017, his wife sought a second opinion from another GP. This time they were referred to a surgeon, who found that the cancer had spread from the man's ear to his lymph nodes, and removed it on April 11, 2017.

He was then referred for radiation therapy, but died in 2018.

Hill found that both the GP and the skin clinic breached the Code of Health and Disability Services Consumers' Rights, and ordered both to apologise to the man's widow.

"I would like to express my sympathies to [the widow] and her children for the loss," Hill said.

He also recommended that the skin clinic change its processes to "ensure that a consumer's GP be notified when a patient is found to have a lesion of significance at a free skin check, and undertake an audit of 30 skin cancer removal procedures".

"This report highlights how important it is for providers who are involved in a consumer's care to communicate effectively with one another, and to have good systems in place for sharing clinical information," he said.


The man's GP said that she had intended to refer him to a specialist to remove the lump on his ear when he first came to see her in June 2015.

"She said that she did not offer to remove the lesion as she felt it was beyond the scope of her expertise. [She] stated that [the man] raised four medical problems during his appointment and as a result it took longer than 20 minutes," Hill's report says.

"The referral was not made at that time as [the GP] inadvertently forgot to set a task reminder to write the referral."

When questioned by Hill's investigators, she said "I am at a loss as to how this could have happened".

"She said that this would be the first time in her many years of general practice that she had omitted to set a task for a referral to be done," the report says.

The doctor at the skin clinic said she did not send her biopsy report on the ear to the man's GP because the man "asked that I not send my biopsy result or my consultation notes to his GP as he did not want her to think he was going behind her back".


Instead the man himself rang a nurse at his GP's clinic, so when he came back for his check-up in April 2016 the skin clinic did email notes about the consultation to the GP.

But the notes stated that it was an "initial consultation", did not mention his ear surgery, and described his medical/skin cancer history as "nil".

"[The skin cancer doctor] explained that she recorded this because the SCC was a current rather than a past problem," the report says.

The man went back to the skin clinic on September 15, 2016, with another lump on the same ear. This time the biopsy showed that the lump was "benign", and the clinic again sent this report to the man's GP with no mention of the previous year's surgery.

On October 1, the skin clinic doctor wrote to the GP stating an "action plan" to take another biopsy to exclude a possibly more dangerous form of cancer.

This time the letter included: "Lesion on [right] ear: painful and niggling since excision of the SCC last year."


This was the first time the dangerous SCC and resulting surgery had been mentioned to the man's GP, and she told Hill's investigators that she didn't notice the reference.

She said that, if she had noticed it, she would have referred the man for a new biopsy immediately when he came back to her in January 2017 with the lump on his neck.

Instead, she referred him for blood tests and then to the haematology service at the local hospital stating: "I think this is a benign lymph gland or reactive." She did not mention the previous more dangerous cancer.

The haematology service decided that it didn't need to see him. It advised the GP to monitor the man's blood count every three months and refer him back if his blood counts escalated rapidly or he developed any other symptoms.

When he went back to the GP on March 10, "the lump behind his ear had grown and he was experiencing a lot more pain".

This time the GP referred him for surgery to remove the lump, providing the benign biopsy result and not mentioning the previous SCC. So the referral was given priority three - to be seen "within four months".


The man's wife didn't wait, and the couple got the tumour removed on April 11.

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The GP's medical centre told Hill that, after reviewing the case, it now texts patients to confirm that it has made a referral and asks them to let the clinic know if they don't hear from the service they are referred to within a month.

The skin clinic doctor said she "now has 20-minute consultations to allow more time for reviewing past notes, performing examinations and writing detailed notes".