Decision Report 201810348

Summary

Ms C, a support and advocacy worker, complained on behalf of her client (Ms A) who was treated for an abscess in her breast which failed to heal. Subsequently, a tissue sample was sent for tests and Ms A was diagnosed with breast cancer. Ms A considers that there was an unreasonable failure to consider cancer as a possible diagnosis at an earlier stage and that this contributed to the delay in providing diagnosis and treatment. Ms A also considers that concerns she raised about a possible cancer diagnosis were not taken seriously.

We took independent advice from an appropriately qualified doctor. We found that, although it was not reasonable to expect a cancer diagnosis to be considered sooner, excised tissue from two operations should have been sent for examination, which may have facilitated earlier diagnosis. On balance, we upheld this aspect of the complaint.

In relation to communication, we considered that the clinical records evidenced reasonable communication. Therefore, we did not uphold this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms A for failing to send tissue removed during surgical procedures for histological examination, and the likely delay in diagnosis this resulted in. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

What we said should change to put things right in future:

• All tissue removed during a surgical procedure should be sent for histological examination, unless it is considered not necessary by the operating surgeon and such justification is documented in the patient’s notes.

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.