The complainant (C) had a family history of breast cancer and was referred to the high risk/family history service for monitoring. C attended appointments with the high risk/family history service to have regular mammogram scans carried out. In 2019, C had symptoms in their left breast. They received a mammogram scan from the symptomatic service and appropriate investigations were carried out to establish the nature of the symptoms in C’s left breast which was confirmed to be a cyst. At this time, C’s right breast was reported as normal. In 2021, a mammogram scan identified abnormalities in the right breast which led to the diagnosis of advanced (stage 3) cancer. C was told that there were abnormalities present in the right breast on the scan in 2019.
C complained that the Board did not follow up on these abnormalities at the time. In light of C’s complaint the Board carried out an internal review, which C was unhappy with as they thought the review would be independent.
The Board said that mammogram scans are reviewed by two consultant radiologists or consultant radiographers who report independently to ensure there are two clinical opinions. The Board’s response to C’s complaint indicated that the abnormalities were considered and discussed at the time but it was decided that they should not be biopsied.
I took independent clinical advice from a consultant radiologist with specific experience in breast radiology (the Adviser). The Adviser highlighted that the Board’s response did not match the medical records, specifically that the abnormalities were not discussed in 2019 and that these were missed. The Adviser said that it was reasonable for the Board to carry out an internal review but the conclusions reached by the review were not reasonable.
I found that the Board failed to provide reasonable care and treatment to C as abnormalities were missed in 2019. Therefore, the opportunity for early diagnosis was missed. I found that the internal review was unreasonable due to the conclusions reached and that the Board did not appear to be holding appropriate meetings in line with relevant standards. I do not consider that the Board demonstrated they have learned from what happened in this case.
My investigation identified some issues with the way in which the Board investigated and responded to C’s complaint. As mentioned above, I found the medical records did not support the Board’s response. On seeing a draft version of this report, the Board clarified that the abnormalities were not identified or discussed in 2019, and that they were referring to a meeting that was held in 2021. I considered that this should have been made clearer in the complaint response. I found the Board’s handling of C’s complaint to be unreasonable.
As such, I upheld C’s complaints.
Redress and Recommendations
The Ombudsman's recommendations are set out below:
What we are asking the Board to do for C:
| Complaint number |
What we found |
What the organisation should do |
What we need to see |
|---|---|---|---|
|
(a) and (b) |
|
Apologise to C for:
The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets. |
A copy or record of the apology By: 31 August 2023
|
We are asking the board to improve the way they do things:
| Complaint number |
What we found |
What should change |
What we need to see |
|---|---|---|---|
|
(a) |
|
When mammograms are undertaken on patients presenting with issues in one breast, radiologists should consider and fully report on the findings in both breasts. There should be appropriate consideration given to carrying out a biopsy when abnormalities such as definite and sizeable calcification are present on a mammogram and the decision in this regard recorded. |
|
| (b) |
|
An urgent meeting (or meetings) held in line with the Standards to discuss a sample of breast radiology cases from 2021 to date (at least six per year, pro rata for the current year). These cases should be selected in line with the Standards i.e. that are clinically important and have an educational message that would benefit their colleagues. The meeting(s) should be chaired by an independent person external to the Board, with the appropriate level of expertise and experience. This is to provide assurance about the independence of the meeting(s). The meeting(s) should
|
This office and the complainant should be informed of
Meeting held by: 31 October 2023 Results of meeting and (as relevant) any action plan by: 1 November 2023
|
| (b) | We found that the Board’s practice of excluding breast radiology cases from radiology education and learning meetings does not appear to be in line with the Standards for Radiology Events and Learning meetings. |
Systems and arrangements should be in place to support all radiology staff and ensure radiology education and learning meetings are held in line with the Standards. Assurance that the Board will follow the Standards consistently in the future. |
By: 2 September 2023 |
We are asking the board to improve their complaints handling:
| Complaint number |
What we found |
Outcome needed |
What we need to see |
|---|---|---|---|
|
(a) |
We found that information included in the final response to C’s complaint was not supported by the medical records. |
Complaint investigations should be carried out in line with the NHS Model Complaints Handling Procedure. They should be: accurate in their findings and conclusions, clear, and supported by relevant evidence, such as, medical records.
|
Evidence that the findings of this investigation have been fed back to relevant staff in a supportive way for learning and improvement and to avoid a similar mistake being made again. Evidence that demonstrates how the Board ensure decisions are accurate and based on available evidence. By: 2 September 2023 |
Feedback
Points to note
In this case, the complainant was given the impression that an independent review would be carried out as part of the complaints investigation process. However, it was an internal review that was carried out. Whilst it was reasonable for an internal review to be carried out, I consider that better and clearer communication about this in advance of the review would have been beneficial for the complainant. This would likely have set the complainant’s expectations about what action the Board would be taking and what type of outcome they could expect.
I would ask that the Board reflect on this point and consider this feedback when handling similar situations in the future.
Complaints handling – responding to an SPSO investigation
When organisations are notified of our intention to investigate a complaint they are asked to provide all information relevant to the complaint, including any relevant policies or procedures.
It is disappointing that the Board provided information about radiology meeting standards only once my draft report was issued for comment, and further information only when provided with details about adjustments made to my report in light of that information. This information was relevant to the complaint and particularly important to our investigation of head of complaint (b). This information could have, and should have, been provided at an earlier stage.
I draw the Board’s attention to this point and ask that when responding to enquiries by my office in the future they ensure all relevant available information is provided at the start of our investigation.
In this case, the failure to do this resulted in avoidable delay in finalising my report, and I ask the Board also to reflect on the impact this would have on the complainer and the Board’s own staff.