Dermatologist Performed Surgery On Old Scar Instead Of Skin Cancer

Deputy Health and Disability Commissioner Rose Wall today released a report finding a dermatologist in breach of the Code of Health and Disability Services Consumers’ Rights (the Code) for failures in his care of a woman undergoing surgery for skin cancer.

The woman, aged in her forties at the time of events, was referred to the dermatologist after a lesion was identified on the left-side of her forehead. It was confirmed to be a basal cell carcinoma lesion and the woman underwent Mohs surgery (a precise surgical technique to treat skin cancer).

Around 24 hours after the surgery, when the woman’s dressings were being changed, it was discovered that the dermatologist had performed the surgery at the incorrect site - on an old chickenpox scar above the actual confirmed lesion.

Before the surgery, the dermatologist had assessed the woman’s forehead and identified what appeared to be the lesion. However, he had failed to confirm the site with the patient by holding a mirror or reviewing the previous photograph of the skin cancer site.

"This report highlights the basic requirement of undertaking appropriate checks to ensure surgery is performed at the correct site," said Ms Wall.

"By failing to confirm the site of surgery correctly and subsequently performing the surgery at the wrong site, the dermatologist failed to provide the woman with an appropriate standard of care."

The Deputy Commissioner considered that the events in this case were an individual error and are not indicative of wider systemic or organisational issues at the dermatology clinic.

Ms Wall acknowledged that changes have been made to both the dermatologist’s and the dermatology clinic’s practice, and an apology letter had been sent by the dermatologist to the woman.

She recommended that the dermatologist arrange for an audit of the next three months of the Mohs surgeries he performs, to ensure that new additions to the consent form and intra-operative theatre record are being used.

The full report on case 18HDC02251 is available on the HDC website.

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