Decision Report 201300819

Summary

Ms C complained that after reconstructive breast surgery, there was an avoidable delay by staff at the Royal Alexandria Hospital in diagnosing that she was suffering from a hernia (a condition where an internal part of the body pushes through a weakness in the muscle or surrounding tissue). She said that she complained several times to staff at the hospital that there was a large protrusion on her waist on the side of the reconstruction and that she was in pain, but that this was not addressed appropriately. Ms C also said there was an unreasonable delay of five months between an ultrasound scan (a scan that uses sound waves to create images of organs and structures inside the body) that showed there was a problem, and a CT scan (a scan that uses a computer to produce an image of the body) that confirmed she had a hernia.

We obtained advice on this case from one of our medical advisers, a general surgeon with a specialist interest in breast surgery. The adviser said that in the 12 months following surgery, the board acted in an appropriate and reasonably timely manner in dealing with Ms C's symptoms, as the likelihood was that the underlying cause of the pain and swelling was commonly recognised complications of her surgery. The adviser said it would not have been acceptable to carry out surgery based on the results of the ultrasound, without a CT scan to help identify the problem.

The adviser confirmed, however, that there was an unacceptable delay between the ultrasound report 12 months after surgery and the CT scan report that confirmed the hernia more than five months later. Ms C suffered a prolonged period of pain and discomfort from her hernia as a result. The adviser noted that Ms C's hernia was recorded by the board as having increased in size during the three months following the ultrasound report. However, he explained that such hernias were generally slow growing, wide necked and very rarely life threatening and that the delay did not change the final outcome in Ms C's case.

Recommendations

We recommended that the board:

• feed back our decision on this case to the staff involved to ensure that a similar situation does not occur in future; and
• provide Ms C with a written apology for the failures identified in our report.