Melanoma Concern: Patient Complaint About Missed Diagnosis

Clinical Scenario

Mark Henderson, 42, books an urgent video consultation wanting to discuss a complaint about a previous consultation. One month ago, he was seen by another GP (Dr Jones) for nail discolouration on his thumb, which was diagnosed as a subungual haematoma (bruise under the nail). Mark has since researched his symptoms online and is now convinced it is subungual melanoma. He is angry that this was dismissed, frightened about cancer, and wants both an urgent referral and to make a formal complaint.

What This Case Tests

Managing an angry patient making a complaint about a colleague; conducting a clinical reassessment of the nail lesion; knowing the ABCDE criteria and Hutchinson's sign for subungual melanoma; arranging an urgent 2-week wait referral if clinically indicated; handling the complaint process professionally without undermining the previous clinician.

Common Mistakes Trainees Make

The three most common mistakes are: being defensive about the previous GP's decision (you were not there and cannot judge), dismissing Mark's concern because he has self-diagnosed from the internet (his concern may be clinically valid regardless of the source), and not knowing the features that distinguish subungual melanoma from subungual haematoma (Hutchinson's sign, the ABCDEF criteria for nail melanoma).

The Consultation Challenge

Mark is angry and frightened — a combination that makes for a volatile consultation. He wants two things: a clinical reassessment and a formal complaint. Both are legitimate, and both need addressing.

Start with the anger. Do not become defensive about Dr Jones. You were not present at that consultation and cannot judge the clinical decision. Acknowledge Mark's experience: "I can hear how worried and frustrated you are. I want to take both your health concern and your complaint seriously. Let's start with your health, because that's the priority."

Conduct a thorough reassessment. Ask Mark to show you the nail on video (if resolution allows) or describe it in detail. Key features distinguishing subungual melanoma from haematoma: Hutchinson's sign (pigment extending to the nail fold or surrounding skin — strongly suggestive of melanoma), a dark longitudinal band (melanonychia striata) rather than a focal bruise, lack of proximal migration as the nail grows (haematomas move with nail growth, melanoma does not), and asymmetry or colour variation within the lesion.

If there is any clinical doubt — and with a month of no improvement, there may well be — arrange an urgent 2-week wait dermatology referral. The threshold for referring a suspicious nail lesion should be low. It is far better to refer a haematoma for specialist assessment than to miss a melanoma.

Handle the complaint separately from the clinical assessment. Explain the formal complaint process: Mark can submit a written complaint to the practice manager, which will be investigated under the NHS complaints procedure. He will receive a response within a specified timeframe. Offer the PALS (Patient Advice and Liaison Service) as an additional support. Do not express an opinion on whether Dr Jones was right or wrong — this is for the investigation to determine.

Time check: Spend the first 3 minutes de-escalating the anger and acknowledging both concerns. Conduct the clinical reassessment between minutes 4-7. Make the referral decision by minute 8. Address the complaint process between minutes 9-11. Use the final minute for safety netting and follow-up.

How Examiners Mark This Case

Data Gathering and Diagnosis: Examiners assess whether you conduct a systematic nail lesion assessment: appearance (colour, shape, symmetry), Hutchinson's sign, growth pattern (has it changed since the original consultation?), nail growth migration (haematomas migrate, melanoma does not), history of trauma, and personal/family history of melanoma. They look for whether you use the clinical features to make a reasoned assessment rather than either dismissing or panicking.

Clinical Management and Medical Complexity: Examiners expect a low threshold for 2WW dermatology referral given the clinical uncertainty. They look for knowledge of subungual melanoma features, appropriate use of the suspected cancer pathway, and a professional approach to the complaint (explaining the process without taking sides). A trainee who reassures without referral, or who criticises the previous GP, will score poorly.

Relating to Others: Examiners assess whether you de-escalate the anger effectively, address both the clinical concern and the complaint as separate issues, and maintain professionalism regarding the colleague. Mark should leave feeling that his health concern is being acted on urgently and that his complaint will be properly investigated.

Example Opening

Strong opening: "Hello Mark, I can see you're really worried and frustrated about what happened at your last appointment. I want to take both your health concern and your complaint seriously. If it's okay with you, I'd like to start with your nail — because your health is the most urgent thing — and then we'll talk about the complaint process."

When reassessing: "Can you show me the nail? I'm looking for some specific features. Has the discolouration changed at all since you were last seen? Has it spread to the skin around the nail?"

When handling the complaint: "I understand you want to make a formal complaint, and you have every right to do so. I wasn't present at that consultation, so it wouldn't be appropriate for me to comment on what happened. What I can do is explain the complaint process and make sure your current concern is addressed urgently."

Avoid: "I'm sure Dr Jones made the right decision at the time." (Taking sides before the investigation is inappropriate).

How This Appears in the SCA

This case combines complaint management with clinical reassessment — testing whether you can handle the interpersonal conflict while also making the correct clinical decision. The examiner assesses whether you can be professional about the complaint, thorough in your reassessment, and decisive about referral. Getting drawn into defending or criticising the previous GP loses marks.

Key Statistic

Subungual melanoma accounts for approximately 1-3% of melanoma cases in Caucasian populations but up to 20% in darker-skinned populations. The 5-year survival for early-stage melanoma exceeds 95%, but delays in diagnosis significantly worsen prognosis. Hutchinson's sign (periungual pigmentation) is present in approximately 75% of subungual melanoma cases.

Relevant Guidelines

• NICE NG12: Suspected cancer — recognition and referral
• British Association of Dermatologists (BAD) guidance on nail melanoma
• NHS complaints procedure guidance.

Frequently Asked Questions

How do I differentiate subungual melanoma from a subungual haematoma?

Key differentiators: subungual haematoma migrates proximally as the nail grows (melanoma does not), haematoma often follows trauma (melanoma does not), Hutchinson's sign (pigmentation extending to the nail fold or periungual skin) is strongly suggestive of melanoma, melanoma typically presents as a longitudinal pigmented band rather than a focal discolouration, and melanoma may cause nail dystrophy or destruction. If there is any doubt, refer — the consequences of missing melanoma far outweigh the inconvenience of an unnecessary referral.

How should I handle a complaint about a colleague during a consultation?

Do not defend, criticise, or speculate about the previous decision. You were not there and do not have the full clinical context. Acknowledge the patient's experience: "I understand you're unhappy with what happened." Explain the formal complaint process: written complaint to the practice manager, investigated under NHS complaints procedure, response within specified timeframe. Offer PALS as additional support. Separate the complaint from the current clinical need — address the health concern first.

What is Hutchinson's sign and why is it important?

Hutchinson's sign is pigmentation that extends from the nail bed onto the surrounding nail fold or periungual skin. It is present in approximately 75% of subungual melanoma cases and is a strong indicator of malignancy. Its presence should prompt urgent 2WW dermatology referral regardless of other features. Recognising this sign demonstrates clinical knowledge that differentiates strong SCA candidates.

Should I refer this patient on the 2-week wait pathway?

If there is any clinical doubt about the diagnosis — and a nail lesion that has not resolved or changed over one month warrants doubt — refer urgently. NICE NG12 recommends urgent referral for any suspicious pigmented nail lesion. The threshold for referral should be low because subungual melanoma has a significantly worse prognosis when diagnosis is delayed. It is far better to refer a haematoma than to miss a melanoma.

How do I manage the dual demands of clinical care and complaint handling in one consultation?

Prioritise clinical care: "Let's address your health concern first, because that's the most urgent thing." Then address the complaint process separately. Do not let the complaint discussion consume the clinical assessment time. If needed, offer a separate appointment to discuss the complaint in detail. This structured approach demonstrates that you take both seriously without compromising either.