Decision Report 201909993

Summary

C underwent treatment for abnormal cervical changes. Around nine years later, a cervical smear test showed borderline changes and they were scheduled for follow-up six months later. Their next smear showed changes requiring investigation and C was seen for a gynaecology (relating to the female reproductive system) scan, at which the consultant also carried out a colposcopy (a simple procedure used to look at the cervix). Everything appeared normal but taking C's history into account they were followed up six months later. The follow-up smear showed severe dyskaryosis (change of appearance in cells that cover the surface of the cervix), prompting an urgent referral to colposcopy. C was seen six weeks later and was later informed that they had adenocarcinoma (a type of cancer), and required a radical hysterectomy (surgery to remove the uterus) and adjuvant chemoradiation (additional cancer treatment given after the primary treatment to lower the risk that the cancer will come back).

C complained that their history of three abnormal smears in the ten preceding years should have led to a referral to colposcopy after their first abnormal smear. C believes that if they had been referred to colposcopy and had a biopsy taken earlier, the need for adjuvant chemoradiation could have been avoided. They complained that the board failed to take account their medical history when considering whether to refer to colposcopy or take a biopsy. C also complained about the board dropping them from cancer tracking, and about the delay between biopsy and treatment.

We took independent advice from a consultant obstetrician and gynaecologist (a doctor who specialises in pregnancy, childbirth and the female reproductive system). We found that referral to colposcopy was not indicated earlier, explaining that the first smear was the first abnormal smear in a new episode and the recommendation for repeat in six months was in keeping with the cervical screening programme. We also found that C's examination following the second smear was satisfactory and it was reasonable not to carry out a biopsy at that time. We did not uphold these aspects of C's complaint.

In relation to the cancer tracking, the board accepted that C should not have been dropped as, given C's pathology results, they clearly required further treatment. Tracking is carried out to ensure patients are followed up timeously and within national targets. We considered that it was unreasonable to drop C from tracking, and we therefore upheld this aspect of C's complaint.

Finally, we considered that the delay in seeing C for colposcopy following their severely dyskaryotic smear, and further delay between diagnosis and treatment, was unreasonable. Therefore, we upheld this aspect of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the delay in commencing treatment, recognising the impact this matter had on them. 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:

• The board should meet national targets for the first appointment following referral with an abnormal smear, and following a positive cancer diagnosis.

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.