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Case ref:201804986
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Date:October 2019
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Body:Borders NHS Board
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Sector:Health
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Outcome:Upheld, recommendations
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Subject:clinical treatment / diagnosis
Summary
Mrs C complained that there was an unreasonable delay in diagnosing her with a breast abscess. Following the birth of her child, Mrs C's GP referred her to Borders General Hospital with a suspected breast abscess after she had been suffering from mastitis (when a woman's breast tissue becomes painful and inflamed). On admission, a surgeon said that there was no evidence of an abscess and Mrs C was discharged. Mrs C was due to return for an ultrasound scan the following day, however, the hospital changed her appointment to a later date. In the interim period, Mrs C experienced a deterioration in her condition and was referred back to the hospital. An ultrasound scan was carried out which confirmed that she had a breast abscess, requiring surgery. Mrs C said the length of time that it took for a scan to be arranged meant that there was an unreasonable delay in diagnosing her with a breast abscess and, as a result, she endured significant distress and her baby did not gain weight appropriately due to difficulties with breastfeeding.
We took independent advice from a medical adviser who specialises in breast surgery. We found that an ultrasound scan should have been carried out to investigate the possibility of a breast abscess during Mrs C's first admission, and that the subsequent delay in arranging the scan was unreasonable. We determined that these failings meant that there was an unreasonable delay in diagnosing Mrs C with a breast abscess. We upheld the complaint.
Recommendations
What we asked the organisation to do in this case:
- Apologise to Mrs C for failing to arrange an ultrasound scan within a reasonable time and the associated delay in receiving treatment. The apology should meet the standards set out inthe SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
What we said should change to put things right in future:
- Ensure that ultrasound scans are carried out within a reasonable timeframe in line with the relevant guidance.
We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.