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A man who was turned away by the NHS died of skin cancer aged 24 just two years after deciding against paying an extra cost for a private test.
Gregor Lynn visited his GP in March 2019 after noticing a "nuisance" lesion on the back of his neck but was refused care as he didn’t meet the referral criteria for treatment.
He paid £140 to have it removed privately but didn't pay another £65 for a test to determine if it was malignant.
In a report into prevention of future deaths, Cambridgeshire area coroner Caroline Jones said the procedure is something that would have been free on the NHS.
The lesion returned 14 months later and when Gregor saw his doctor again, he was then referred to a specialist who diagnosed him with skin cancer.
Doctors found that the disease had already spread to his lymph nodes, chest wall and lungs.
Despite undergoing treatment, the cancer spread to his brain and he died at Addenbrooke’s Hospital in Cambridge on July 8, 2022.
An inquest into his death found that he died of natural causes due to a "disseminated metastatic melanoma".
Coroner Jones said she had serious concerns about the case.
The court heard that excised material from the lesion was not sent for histological analysis "likely due to the additional cost associated with having to have the samples analysed privately".
She wrote: "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."
Writing to the Department of Health and Social Care, Cambridgeshire and Peterborough Integrated Care System and NHS England on December 20, she said: "In my opinion there is a risk that future deaths could occur unless action is taken.
"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.
Doctors found that the disease had already spread to his lymph nodes, chest wall and lungs
PA"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."