Gregor Patrick Edward Lynn · Prevention of Future Deaths report

On 29 July 2022, I commenced an investigation into the death of Gregor Patrick Edward Lynn aged 24 years. The investigation concluded at the end of the inquest on 30 August 2023. The conclusion of the inquest was that:

• Gregor died of natural causes due to a disseminated metastatic melanoma
• He had developed a lesion on the back of his neck in March 2019 which was excised privately but the excised material was not sent for histological analysis, likely due to the additional cost associated with having to have the samples analysed privately
• By the time the lesion recurred in May 2020 and was examined under the urgent care dermatology pathway, it was found to be a melanoma which had metastasised and was beyond effective treatment.

In March 2019, the consequence of Gregor not meeting the referral criteria for NHS treatment upon initial presentation with a nuisance lesion to the back of his neck was that he had to self-refer for private treatment at a reported cost of c.£140. He was advised that the additional cost of histological analysis of the excised samples would be c.£65 and so decided not to have the samples sent for analysis.
When the lesion continued to trouble him in May 2020, he returned to his GP who referred him to dermatology, where a further excision was performed and analysed and was found to be melanoma. An ultrasound scan showed that the melanoma had metastasised to his lymph nodes, chest wall and lungs.
Despite immunotherapy and targeted oral therapy, the melanoma continued to metastasise and in June 2022, scans showed that it had spread to Gregor’s brain such that his condition was terminal. He was placed onto a palliative care pathway and following an admission to Addenbrooke’s hospital on 6 July 2022, he died on 8 July 2022.

• 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. Anecdotal evidence received at inquest from treating clinicians was that the further costs associated with histological or other review, which on the NHS would be routinely included within the procedure at no charge to the patient, was a common disincentive to patients who would regularly opt not to have the further tests carried out.
• While it is acknowledged that there have to be criteria for routine and non-emergency procedures to be conducted on the NHS, my concern relates to the disparity in what is included within the treatment when undertaken privately (where histological analysis is a separate and additional cost) and what is routinely included as part of NHS treatment.
• 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, as it is well-established fact that earlier detection and treatment is crucial in minimising the risks of developing metastatic cancers including melanoma.