Medico-legal issues in cryotherapy

Cryotherapy is frequently carried out in general practice, but is often a cause for complaint. By Dr Karen Roberts

  • Patients should be selected carefully and appropriately.
  • Cases concerning cryotherapy that are reported to the MDU arise mainly from failures in practice procedures.

Cryotherapy is a procedure that is commonly carried out in general practice. Provided that patients are selected appropriately and care is taken with the procedure, it offers many patients a speedy and efficient alternative to seeing a hospital specialist. Recent analysis of MDU data, however, reveals that it can lead to complaints and claims. The MDU receives a small but consistent number of claims relating to cryotherapy. Over a recent six-year period, 36 claims have been notified - the majority (86 per cent) in primary care, with the remainder arising from dermatological and ophthalmological practice.

Malignant lesions
In two cases, repeated cryotherapy was administered to lesions that later proved to be malignant, and the resulting claims were settled for a total of £175,590.

In another 13 cases, settlements were made totalling £194,530. Of the remaining cases, 11 are at the investigation stage and 10 have been successfully defended or discontinued owing to the statute of limitations on litigation. In some of the settled claims, other indemnifiers also contributed to the compensation awarded to the claimant.

These cases arose from failure in practice procedures, because of faulty equipment or because the treatment that caused the injury was administered by an unindemnified employee at the practice, for whom all the GP partners were vicariously liable, and some of these GPs were members of other medical defence organisations.

Risk-management advice
Based on common themes that were apparent when the settled claims were reviewed, the following risk management advice may help to avoid the potential risk of complaints and claims following cryotherapy and to improve patient safety.

  • All those carrying out cryotherapy in general practice, including nurses and GPs, should be adequately trained in the procedure and skills should be kept up-to-date.
  • Ideally, training plans should be documented, for example, in a doctor's or nurse's personal development plan.
  • It is important that all staff agree protocols clearly setting out their roles and responsibilities for the relevant procedure. The protocol could include risks patients should be warned about, the process for seeking and documenting informed consent and advice that should be given about aftercare. In terms of cryotherapy, the risks could include recurrence, blistering or scarring and varying degrees of pain.
  • It may be useful to consult local dermatology services to ensure that staff training and proposed protocols accord with any locally agreed or national guidelines.
  • Equipment should be regularly serviced and service records maintained.

One member of the practice - perhaps the practice manager or a nurse involved in administering the treatments - should take responsibility for ensuring that suitable maintenance schedules are also followed.

Example case
A patient consulted his GP because he had discovered a small lesion on his leg. He complained that it had recently become more pronounced and bled once, when he knocked it. The GP thought it was likely to be a wart and referred the patient for cryotherapy at the practice's minor surgery clinic. A colleague treated the lesion and recommended that the patient should return to the surgery two weeks later for a check-up.

The patient returned twice more to the practice during the next two months, to complain that the wart was still visible. At the first review, he was again treated with cryotherapy, but at the second, the lesion was excised and sent for histology.

The histology report revealed a malignant melanoma and on reviewing the result, the GP intended to ask the receptionist to make an urgent appointment for the patient. Unfortunately, he was called away and forgot and the patient also forgot to contact the surgery for the results.

Six months later, the patient returned to the surgery again, complaining that the lump had recurred, and at this point, the GP discovered the histology report. He apologised for the delay and made an urgent referral to hospital, where the patient was treated for malignant melanoma.

The patient made a claim against the practice, which was subsequently settled for £2,500, on the basis of the additional pain and suffering over the six month period before diagnosis. Fortunately, the delay did not affect the patient's prognosis and he made a good recovery.

- Dr Karen Roberts is a clinical risk manager at the Medical Defence Union

Further reading
Cryotherapy Caution . MDU Journal, Volume 22, Issue 2, December 2006

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