Source · PHSO decision

A practice in the North Yorkshire area

Ref: P-002574 Statement Decision date: 23 April 2024 Jurisdiction: NHS in England Closed After Initial Enquiries

Mrs V complained a nurse's inadequate pelvic examination delayed her cancer diagnosis by three months, resulting in life-changing surgery and non-curative treatment.

Outcome

AI summary
The complaint was closed. The Ombudsman advised Mrs V could explore taking legal action regarding the delayed assessment and diagnosis.

The complaint

4. Mrs V complains a nurse did not carry out a thorough pelvic examination on 27 September 2021.

5. Mrs V says that because of this her cancer diagnosis was delayed by three months. She tells us she has been diagnosed with squamous cell carcinoma (a common type of skin cancer) of the anal canal. She has had to have life changing surgery including a hysterectomy and surgery to remove her rectum, anus and sigmoid colon leading to a permanent colostomy (a procedure to make an opening for the colon through the abdomen). She says she is now on systemic chemotherapy rather than curative (treatment to target the entire body but not to cure the cancer). She believes being diagnosed sooner would have led to a complete cure and her full recovery.

6. Mrs V says she is unable to have sexual intercourse and her mental and emotional health have been massively affected.

7. Mrs V would like a financial payment and for the Practice to acknowledge its failings.

Background

8. On 27 September 2021, Mrs V attended the Practice for a routine smear test. She told the practice nurse she could feel a lump on the back wall of her vagina. The nurse examined Mrs V while she was lying down and said they could not feel anything. Mrs V suggested it was more prominent when she was sitting up, but the nurse did not examine her in an upright position. The nurse took no further action.

Findings

10. The Health Service Commissioners Act 1993 (the law) says we cannot investigate a complaint where a person has (or had) the option to take legal action, unless we consider this is (or was) unreasonable in the circumstances. We have discussed this with Mrs V to understand her circumstances and the outcome she wants. We do not consider whether legal action would succeed, but whether it would be a reasonable option to look into.

11. Clinical negligence takes place when a patient who had treatment becomes injured as a result of that treatment. Failure to give appropriate treatment could also amount to negligence.

12. Mrs V wants a financial payment. She not sure how much could be paid in a case like hers and would like to discuss her complaint with a solicitor.

13. We think Mrs V could take legal action by making a clinical negligence claim. We discussed with Mrs V if there were any barriers to her doing this, like her chemotherapy. Mrs V told us there are no barriers to her exploring her legal options so we have decided it is reasonable for her to do this.

14. We have advised Mrs V if there are any outstanding concerns that cannot be achieved by making a legal claim, or if she finds she is unable to make a claim, she can bring the complaint back to us to consider. We have told Mrs V we will consider the time limit should she return to us.

Our decision

1. We have carefully considered Mrs V’s complaint about a GP practice in the North Yorkshire area (the Practice).

2. We are very sorry to hear how Mrs V was affected by the delay in her assessment and diagnosis. We recognise this has been a very difficult and distressing time for her.

3. We think Mrs V could take legal action on the matter she has brought to us.

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Decision details

Reference
P-002574
Decision type
Statement
Jurisdiction
NHS in England
Decision date
23 April 2024
Outcome
Closed After Initial Enquiries

Complaint summary

AI
Summary
Mrs V complained a nurse's inadequate pelvic examination delayed her cancer diagnosis by three months, resulting in life-changing surgery and non-curative treatment.

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Data from PHSO under Open Government Licence.