A GP's urgent request for his patient to see a skin specialist went unanswered for a number of months, a Medical Council fitness-to-practise inquiry has heard.
The doctor referred the then 58-year-old patient to Tallaght Hospital in January 2008 because of concerns over a mole on his chest.
But despite writing 'urgent' in block capitals on the referral letter, and despite redrafting the letter three months later, the patient, identified only as Mr S, waited months for a response. He finally got an appointment for July 2008.
He died on December 6, 2009, less than a month after learning the mole was a form of the deadly skin cancer, melanoma.
The inquiry is hearing evidence on whether Mr S's supervising surgeon, Mr Masood Ahmed of Dublin 18, is guilty of poor professional practice for failing to act on a biopsy report showing Mr S had a melanoma and for failing to ensure his patient received follow-up treatment. The biopsy report was completed in August 2008 but its results were only made known to Mr S in November 2009 when he went to an A&E department complaining of gastrointestinal pain.
Mr Ahmed's lawyers maintain the consultant never received the biopsy report and that Mr S's death was the result of a multi-factorial failure at St Columcille's Hospital, Loughlinstown, Co Dublin.
The patient, who was 59 at the time of this death, had the mole removed in St Columcille's by Mr Ahmed's registrar, Dr Fasil Nasir, on August 14, 2008.
Following the operation, a sample was sent to the pathology department for analysis. Consultant histopathologist at St Columcille's Dr Niamh Nolan told the inquiry that she didn't agree with Dr Nasir's contention that a phone call was merited once the sample was discovered to be a melanoma.
The inquiry heard four copies of Dr Nolan's report were sent out. However, the inquiry was told Dr Nasir and Mr Ahmed didn't receive their copies.
The inquiry heard from expert witness Anthony Peel, a consultant surgeon in Britain, that, in his opinion, hospital systems do fail and that Dr Ahmed had a personal responsibility to ensure there were safeguards in place. "The buck stops with the consultant in charge," Mr Peel remarked.
The inquiry is due to hear testimony from Mr Ahmed when it resumes on June 15.