NHS referral guidelines risk lives, says Cambridgeshire coroner

Cambridgeshire's coroner said Gregor Lynn, 24, developed a lesion on the back of his neck

The death of a man from skin cancer after he decided not to pay privately for a medical test was "of concern", a coroner said.

Gregor Lynn, 24, developed a lesion on his neck in 2019 but did not meet the referral criteria for NHS treatment.

It was removed privately but the sample was not analysed, with cost an apparent "barrier", said Caroline Jones.

The Cambridgeshire coroner warned of "a risk of future deaths" due to NHS referral guidelines.

Mr Lynn referred himself for private treatment to remove the lesion at a cost of about £140, the assistant coroner wrote in a prevention of future deaths report.

Ms Jones said he was "advised that the additional cost of histological analysis of the excised samples would be about £65 and so decided not to have the samples sent for analysis".

'Terminal condition'

Mr Lynn returned to his GP in May 2020 because the lesion "continued to trouble him" and was referred to dermatology.

It was removed, analysed and found to be melanoma, which an ultrasound scan revealed had metastasised to his lymph nodes, chest wall and lungs.

Despite treatment, "in June 2022, scans showed that it had spread to Gregor's brain, such that his condition was terminal", said Ms Jones.

Mr Lynn died in July 2022 and an inquest last year concluded he died of natural causes due to a disseminated metastatic melanoma.

Ms Jones has written about her concerns to the Department of Health and Social Care, Cambridgeshire and Peterborough Integrated Care System (CPICS) and NHS England.

She said: "I was not able to conclude that, had the sample been sent for analysis in March 2019, any sign of melanoma would have been detected.

"Nevertheless, it is of concern that the barrier to undergoing a complete procedure, including histological analysis, appears to be one of cost."

"It therefore seems to me that there is a risk of future deaths if patients not meeting the NHS referral criteria, who have to pay for procedures to be carried out privately, opt on cost grounds not to have the histological analysis which would otherwise be provided on the NHS at no charge."

The parties Ms Jones served her prevention of future deaths report on must respond within 56 days.

A spokesperson for the CPICS said: "We want to offer our sincere condolences to Mr Lynn's loved ones. We are considering the coroner's report and will be responding to their concerns in due course."

An NHS spokesperson said: "NHS England extends its deepest sympathies to the family and friends of Mr Lynn. We will now carefully consider the Prevent of Future Deaths Report sent to us by HM Coroner and respond in due course."