Sample policy · Dermatology

Skin cancer recognition and urgent referral policy (dermatology)

Statutory anchor: Regulation 12 (safe care and treatment), Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (SI 2014/2936). The primary clinical source for this policy is NICE NG12 (Suspected cancer: recognition and referral), read with NICE NG14 (Melanoma) and British Association of Dermatologists guidance. · primary source

1. What the regulation says

Care and treatment must be provided in a safe way for service users. (Reg 12(1) (the headline duty))

assessing the risks to the health and safety of service users of receiving the care or treatment, (Reg 12(2)(a) (risk assessment))

doing all that is reasonably practicable to mitigate any such risks, (Reg 12(2)(b) (risk mitigation))

ensuring that persons providing care or treatment to service users have the qualifications, competence, skills and experience to do so safely, (Reg 12(2)(c) (staff competence))

where responsibility for the care and treatment of service users is shared with, or transferred to, other persons, working with such other persons, service users and other appropriate persons to ensure that timely care planning takes place to ensure the health, safety and welfare of the service users. (Reg 12(2)(i) (shared / transferred responsibility))

The full text of the regulation is at https://www.legislation.gov.uk/uksi/2014/2936/regulation/12. Where this policy and the regulation diverge, the regulation wins.

2. Plain-English summary

Care and treatment must be provided in a safe way. The regulation lists the areas a provider must address, including risk assessment, risk mitigation, staff competence, safe premises, safe equipment, sufficient equipment and medicines, medicines safety, infection prevention and shared-care planning. Regulation 12 is central to CQC's safety expectations.

3. Purpose

A dermatology service sees skin lesions every day, and a missed melanoma or squamous cell carcinoma can cost a life. This policy sets out how the Service recognises lesions that may be cancer, refers them urgently down the right pathway, and makes sure no patient with a worrying lesion is lost to follow-up.

The Service must verify this policy against current NICE suspected-cancer referral guidance and British Association of Dermatologists guidance before adoption.

4. Sources to verify before adoption

5. Scope

This policy applies to:

6. Recognising a lesion that may be cancer

Clinicians assess lesions against current criteria, including:

The clinician uses dermoscopy where competent (see the dermoscopy and lesion documentation policy) and documents the assessment.

7. Urgent referral

Where a lesion may be cancer, the Service refers it urgently down the right pathway, within the timescale the guidance sets, and does not delay by watching and waiting where the criteria for referral are met. The referral:

Where the Service itself excises a lesion that may be cancer, it follows the minor skin surgery and specimen handling policy, including correct specimen handling and acting on the histology result.

8. Safety-netting the patient

The patient is told, in a form they can keep:

The Service does not rely on the patient alone to drive the pathway.

9. Tracking referrals and results

The Service runs a system so no urgent referral or pending result is lost:

10. When something is missed or delayed

A missed or delayed skin-cancer diagnosis is treated as a serious patient-safety matter. It is logged, investigated, and the duty of candour is opened where the threshold is met. The Service reviews how the lesion or result was missed and changes the system to prevent a repeat.

Operational controls to adapt

Roles and responsibilities

Skin-cancer recognition and referral procedure

  1. Assess the lesion systematically. Record history, symptoms, change, risk factors, clinical findings and dermoscopy findings where used.
  2. Apply current referral criteria. Use NICE suspected-cancer criteria and local pathway rules, and do not monitor where urgent referral criteria are met.
  3. Explain the referral. Tell the patient why urgent referral is needed, what should happen next and what symptoms should prompt immediate contact.
  4. Send the referral with evidence. Include lesion site, size, history, risk factors, images, dermoscopy findings and urgency.
  5. Track acceptance. Confirm the referral has been sent, received and accepted by the receiving service.
  6. Chase missing progress. Chase if the patient has not received an appointment, the result is overdue, or the receiving service asks for missing information.
  7. Act on results. Review specialist advice, histology and outcome letters, communicate the result to the patient, and arrange any follow-up.
  8. Escalate failures. Open an incident for missed referral, delayed referral, lost result, missed cancer concern, DNA with unresolved risk or failure to communicate a malignant result.

Records and register links

The referral record should include:

Missed or delayed referral, lost result and missed cancer concerns are opened on the incident register. Repeated referral or tracking failures are added to the risk register and improvement-actions register.

11. Training

Clinicians who assess skin lesions keep their skin-cancer recognition current, including dermoscopy where they use it, and are refreshed on a stated cadence. The Service records who is competent and the next refresher date.

12. Audit cadence

The Service checks, on a stated cadence, that:

The Registered Manager and the clinical lead review the results and record the improvement actions that follow.

13. Sources and further reading

This template is based on CQC's guidance for providers and managers, the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, and other topic-specific legislation and guidance listed below. It is a starting point for adaptation, not a substitute for legal, clinical, HR, safeguarding or specialist professional advice.

Related reading

14. When to seek further advice

Seek specialist advice where the issue involves serious harm, safeguarding, deprivation of liberty, restraint, children, professional misconduct, controlled drugs, radiation, termination of pregnancy, infection outbreak, water safety, employment dismissal, DBS barring referral, or regulatory enforcement.

15. Document control

Version Date Author Changes
v1.1 2026-07-14 Verivius (sample) Added role ownership, urgent-referral procedure, record fields, register links and related reading.
v1 2026-06-10 Verivius (sample) Conformed to the Verivius policy standard: added statutory anchor, verbatim Regulation 12 text, plain-English summary, and standard sources / advice / document-control blocks. Original operational sections preserved and renumbered.

This sample policy template was issued by Verivius. It is a template, not a substitute for legal advice or the tenant's own policy-development process. Where this template and live law or regulator guidance diverge, the live source wins.

What good looks like here

Written from an ex-CQC inspector's chair, but the point is safe, well-led care your team can stand behind. Each row shows what strong evidence looks like, what thin evidence looks like, and where the expectation comes from.

Skin cancer is one of the few clinical risks where the harm accrues quietly in the gap between two handovers: the referral that leaves the service, and the histology or specialist letter that should come back. A melanoma that is watched for a season rather than referred does not announce itself, and a patient told the lesion looked reassuring has no symptom that would bring them back through the door. That makes the tracking record a clinical safeguard rather than paperwork, because the referral log and the results fail-safe are the only things standing between a letter that went nowhere and a thicker tumour by the time anyone looks again. The patient feels it as abandonment long before anyone calls it a delay: someone left to chase their own urgent appointment learns that the concern they raised was not really being held by anyone. A service that can show which lesions it decided not to refer and why, and can account for every result it is still waiting on, gives its clinicians the confidence that watchful waiting was a judgement rather than a gap.

  1. The fail-safe on histology and pathology results actually fires: a result that does not come back is chased, not simply waited for, so no patient is left waiting on a result that never arrived.

    Strong evidence: The results-checking record and its fail-safe (section 9), and the audit line confirming no pathology result is left outstanding unnoticed (audit cadence, section 12).

    Weak evidence: A results inbox that only shows what arrived. Staff can produce every histology report and specialist letter they received, but nothing lists what is still awaited, so a specimen mislaid by the laboratory or a report filed to a clinician who has left leaves no trace at all. The audit line reads "all results checked" with no count of results outstanding to check it against, which means the fail-safe can only ever confirm what turned up.

    What the regulator expects to see. Not a law in itself, but CQC judges you against it, so an inspector will look for it and expect a reason where you depart from it.

  2. Every urgent referral is tracked through to the patient being seen, not treated as finished once the letter is sent.

    Strong evidence: The referral log confirming the referral was sent, received and accepted, plus the appointment booked or the patient's non-attendance and the resulting outcome (section 9, procedure steps 5 and 6).

    Weak evidence: A referral log whose final column is "letter sent" with a date and nothing after it. No confirmation that the receiving service accepted it, no appointment date, and non-attendance recorded as a bare "did not attend" with no follow-up entry, so a patient whose referral never arrived and a patient who was seen and reassured look identical in the record.

    The recognised standard from a professional or clinical body, such as NICE or a royal college. Not a legal duty, but the accepted mark of safe practice, and a departure needs a documented reason.

  3. A lesion meeting the referral criteria is referred rather than watched and waited, and the record names the criterion used or the reason referral was not made, so the next clinician to see the patient knows which it was.

    Strong evidence: The lesion assessment documented against NICE (National Institute for Health and Care Excellence) suspected-cancer criteria and the local pathway, recording the criterion used or the reason for not referring (section 6, procedure step 2, records and register links).

    Weak evidence: Lesion entries reading "mole, monitor" or "benign appearance, review if changes", with no record of which criterion was tested or why urgent referral was not made. Where the patient raised their own concern about a changing mole, the notes show the clinician's reassurance but not that the concern was weighed against the referral criteria at all.

    The recognised standard from a professional or clinical body, such as NICE or a royal college. Not a legal duty, but the accepted mark of safe practice, and a departure needs a documented reason.

  4. A malignant or unclear result triggers prompt action and the patient is told, with the record showing who told them and when, not left while the result sits unactioned.

    Strong evidence: The results lead's escalation of malignant or unclear results and the record confirming the patient has been told (roles and responsibilities, section 9).

    Weak evidence: A malignant histology report initialled or marked as seen in the results system, with no entry showing who told the patient, when, what was said and what was arranged. Unclear results are the weakest spot: a report advising clinical correlation gets filed as seen because it is not a clear positive, with no escalation recorded and no next step booked.

    The recognised standard from a professional or clinical body, such as NICE or a royal college. Not a legal duty, but the accepted mark of safe practice, and a departure needs a documented reason.

  5. A missed or delayed diagnosis is logged and investigated, with the duty of candour owed to the patient considered against the threshold that applies to the Service, not quietly corrected.

    Strong evidence: The incident-register entry and investigation for a missed or delayed diagnosis, and the duty-of-candour record where the Regulation 20 harm threshold is met (section 10).

    Weak evidence: The delay appears only as a later correction in the clinical notes, with no incident-register entry, so it never reaches the governance review or the themes that would change the system. Where an entry does exist, the candour section is blank or reads "not applicable", with nothing showing who assessed the harm against the Regulation 20 threshold or what the patient was told.

    A legal duty. This comes from legislation that applies to your service, so meeting it is not optional. The exact provision is cited beneath the badge.

    Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, reg 20(2)-(3) and reg 20(8) (notifiable safety incident threshold), with reg 17(2)(b)

Related

Last verified 20 July 2026

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Last reviewed 10 June 2026