Decision Report 201504352

Summary

Mrs C's GP referred her urgently to University Hospital Crosshouse in April 2014 as it was suspected that she had breast cancer. However, after examination and ultrasound, her tests were found to be normal. She was told that everything was satisfactory but, because of a family history of breast cancer, she would be referred to the genetics department for risk assessment. Mrs C said that she was never contacted by the genetics department and because of her results, she said she was unconcerned.

In November 2014, Mrs C was re-referred to hospital. She had a breast lump and breast cancer was confirmed. Mrs C complained that her illness should have been diagnosed earlier. She said that because it was not, her cancer had grown and she required to have a double mastectomy. She said that insufficient investigation was made in April 2014. She complained to the board who said that as no abnormality had been found initially, at either the scan or on examination, there had been no clinical indication to refer her for a mammogram and there was no abnormality to biopsy.

We took independent advice from a consultant breast surgeon and we found that, in view of her presenting symptoms, Mrs C had been treated reasonably and appropriately. She had been examined and assessed in terms of best clinical practice. Nevertheless, despite this, it was likely that her breast cancer had been missed the first time. There was nothing the board could have done to have prevented her delayed diagnosis. For this reason, the complaint was not upheld. However, it had been intended to see Mrs C in the genetics department for a risk assessment but it appeared that a letter inviting her to provide information about her family may not have been sent. Accordingly, the board were asked to apologise although, even if the letter had been sent, Mrs C's outcome would have been unchanged.

Recommendations

We recommended that the board:

• make an appropriate apology to Mrs C.