Decision report 201003315

Summary

Mrs C was diagnosed with breast cancer and agreed after discussion with medical staff that she would have chemotherapy followed by breast conserving surgery. Mrs C completed her chemotherapy treatment, but shortly before her planned surgery (some six months after her diagnosis) she found out the full extent of the disease and decided to have the breast surgically removed. Mrs C complained that healthcare professionals did not communicate the full extent of the disease to her or report it fully within a reasonable time. She said that as a result, her treatment plan was initially based on the incorrect belief that breast conservation was possible. Mrs C also raised a number of concerns about the board's complaints handling.

We took advice from our relevant medical advisers and found that there were failures in the board's management of Mrs C's breast cancer, and that the process to ensure that healthcare professionals communicated effectively with each other and with Mrs C was not followed. Although we considered that the board's failures made no difference to the treatment and outcome for Mrs C, they did cause her additional stress at a very difficult time. We also found some aspects of the board's complaints handling was inadequate in that there were delays and the board failed to keep Mrs C informed.

Recommendations

We recommended that the board:

• review their practice on management of patients with breast cancer to ensure it meets Scottish Intercollegiate Guidelines Network guidelines, particularly in relation to the multidisciplinary team process;
• review their complaints process to ensure it meets the requirements of the NHS complaints procedure; and
• apologise to Mrs C for the failures identified.