Decision Report 201401181

Summary

Miss C told us she was not treated with reasonable courtesy during a breast screening appointment. She said she did not receive adequate information before, during, or after the appointment and was unprepared for her experience which she found both distressing and painful. Miss C said she told staff that she was afraid of hospitals, needles and the sight of blood. She complained in particular about her x-ray guided biopsy (where a special machine uses x-rays to help guide the radiologist to the site of an abnormal growth to take a tissue sample). She said she did not know what was involved with this procedure, or about the side effects or aftercare. She said she did not get the chance to ask questions or speak to anybody about it. Miss C told us the treatment room was full of people and that no introductions were made. Her treatment lasted more than four hours, although her appointment letter said that the appointment might take up to three hours.

We took independent advice on this complaint from one of our medical advisers, who is an experienced GP. We found evidence that staff checked she was available to stay for the biopsy, but not that they explained in any detail what it would entail or how long it would take. We found confused and conflicting evidence about who was present during the procedure, and it was clear that people in the room were not introduced to Miss C as they should have been. The board had already apologised for the distress Miss C experienced on the day of her appointment. They acknowledged the importance of giving information, obtaining consent and introducing members of staff. We found that Miss C was given only limited information in advance, which did not meet her needs. Although she could have taken a more cautious approach to giving consent for the procedure, it was the board's responsibility to tell her what the biopsy involved and what degree of discomfort she might experience afterwards. They should also have offered her the opportunity to ask any questions before asking for consent.

Although we upheld Miss C's complaint and made recommendations, we commended the board for meeting with her to hear from her first-hand, and noted that the tone and content of their correspondence showed that they wanted to learn from her poor experience and were willing to improve.

Recommendations

We recommended that the board:

• offer an additional apology in light of the failings identified;
• carry out a review of the information and communication needs of patients attending Assessment Clinics, particularly those attending on recall, to ensure that at each stage patients can make informed and supported choices prior to giving their consent; and
• remind staff with responsibility for handling complaints of the correct procedures to follow.