Man Dies After Scalp Lesion Missed During Scan Delays Terminal Skin Cancer Diagnosis

A tragic case of medical oversight has come to light, where a man's life was ultimately lost due to a missed diagnosis of a rare and aggressive form of skin cancer. The incident, which has sparked widespread concern about the standard of care in radiology, highlights the critical importance of thorough and vigilant medical assessments.

The man first developed a cyst on the back of his head in 2019 and was treated at a public hospital. However, his initial referral for further assessment was declined, and a subsequent referral was categorized as routine, with an estimated six-month waiting time. This delay in proper evaluation would prove to be life-altering.

In January 2020, the man underwent an MRI for a completely unrelated issue—his hearing loss. During this scan, a noticeable mass on his scalp was not reported. He returned to his GP and the hospital the following month, as the cyst had become painful and was growing larger. Despite these concerns, he was once again treated and discharged without further follow-up.

It was not until March 2020, when he was reviewed by the ear, nose, and throat service for his hearing loss, that a biopsy was taken for a suspected tumour on his scalp. A scan two weeks later confirmed the mass to be a very rare and aggressive form of skin cancer. An amendment was then made to the original MRI report, identifying a soft tissue mass measuring 4.8 x 2.7 centimetres on the left side of the scalp.

The radiologist who conducted the original MRI scan later expressed deep regret over his failure to identify the lesion. He acknowledged that he had been too narrow in his focus and did not consider the lesion to be a severe departure from the standard of care. However, the independent clinical advice from a neuroradiologist found that the standard of the MRI reporting was 'grossly below the standard expected' of a radiologist.

The radiologist has since reflected on the case and made significant changes to his reporting processes. He now ensures that he reviews the skin on the scalp and surrounding tissue as the final part of his MRI brain reporting process. He has also stopped undertaking out-of-hours reporting when his attention could be reduced.

The man underwent surgery to remove the lesion in April 2020, followed by further surgery in July 2020. However, by this time, the cancer had progressed to an advanced and terminal stage. He made a formal complaint to the Health and Disability Commissioner in 2021, which led to the findings that the radiologist had fallen significantly short of the expected standard of care.

This case underscores the critical importance of vigilance in medical imaging and the need for continuous training and adherence to established protocols. It also serves as a sobering reminder of the potential consequences of even minor lapses in attention during a routine scan.

The radiologist has since expressed his commitment to learning from this experience and ensuring that such a mistake is never repeated. However, the damage had already been done, and the man's life was ultimately lost due to a preventable delay in diagnosis.