Two health professionals failed to monitor and review a bleeding mole on a 65-year-old man, who later died of melanoma, the Health and Disability Commissioner found.

The Health and Disability Commissioner (HDC) Anthony Hill found a registered nurse and a rural nurse specialist failed to provide medical care for the man.

The man was found to have a large bleeding lesion on his upper back, three months after a hip replacement operation.

The rural nurse specialist documented this and advised the man to have it checked by a surgeon at an upcoming consultation.


However, there was no record the surgeon had reviewed the mole.

The nurse specialist failed to formally document a request for medical review, the HDC found.

When the man was admitted into hospital again for the second stage of his hip surgery, a nurse recorded the bleeding mole, but there was no record of monitoring or a medical review of it.

It was not until a physician at the hospital examined the lesion, that it was found to be a malignant melanoma.

He later died as a result of it.

Mr Hill found the rural nurse specialist had failed to instigate a written medical referral or follow up with her colleagues to ensure that a medical review of the lesion took place in a timely manner.

The nurse specialist should have recorded her conversation with the man about the surgeon's review, he said.

"Accurate documentation is a critical element of nursing practice. Clinical records must be accurate and concise, and include the care that is given or planned."


Both health professionals apologised to the man's family.

Mr Hill made a number of recommendations for better communication and documentation.

He also recommended refresher training on assessment, management and monitoring for health professionals who review suspicious skin lesions.