An independent provider in the Shropshire area

3. Miss L complains the Provider failed to correctly report her ultrasound scan on 20 March 2024. She complains it has not taken responsibility for its mistake.

4. She says she suffered with distress and confusion about the incorrect diagnosis. She says it delayed her receiving appropriate treatment for two months. She says during this time she suffered in pain and her cyst then grew in size.

5. She says the Provider not acknowledging what happened has caused her further distress.

6. She would like the Provider to acknowledge what happened and apologise for the mistakes and also make service improvements. She would like a financial remedy.

7. What follows is a summary of events. We have not included all the details as both parties are aware of these.

8. On 8 March 2024, Miss L’s GP referred her to the Provider to conduct an ultrasound as she was reporting right sided abdominal pain. She was post-menopausal, and her GP suspected she may have an ovarian cyst.

9. The Provider performed an ultrasound on 20 March 2024. It diagnosed her with a left sided ovarian cyst.

10. She was later referred to hospital by her GP and was diagnosed with a right sided ovarian cyst and no cyst was identified on the left ovary.

Incorrectly reporting her ultrasound scan

14. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen. We have done this and have not found any indications that something has gone wrong.

15. Miss L complains the Provider reported her ultrasound incorrectly on 20 March 2024. She says it diagnosed her with a left sided cyst. She told us she was later referred to hospital by her GP in May 2024, and she was diagnosed with a right sided cyst and there was no cyst identified on the left side.

16. In its complaint response on 30 May 2024, it said it sent her scans for review by a superintendent sonographer. They concluded there was a cyst identified on the left side ovary and it said the scan was therefore reported correctly.

17. Our adviser reviewed the ultrasound imaging from 20 March 2024. They said there is a simple cyst smaller than 2cm in the left ovary, this is a fluid filled sac that develops on the ovary. Our adviser said Miss L’s ultrasound scan was reported correctly.

18. Section 89 of the GMC guidance says a clinician must make sure any information they communicate as a medical professional is accurate, not false or misleading. From advice sought we understand the ultrasound report has been reported correctly based on the scans. Therefore, the Provider have appropriately reported Miss L’s scan and acted in line with guidance by providing accurate information about her scan.

19. We understand Miss L’s confusion about her diagnosis, considering her right sided pain, and her later being diagnosed with a right sided cyst. We are sorry for the further distress this caused her and that she feels she suffered unnecessarily between March and May 2024. From our consideration, we have seen evidence that the Provider correctly recorded her ultrasound on 20 March 2024. Therefore, without being able to identify a failing, we would take no further action.

Response to the complaint

20. Miss L complains the Provider did not take accountability for what happened and apologised for the impact this had. She says she tried to resolve the complaint locally, but it would not acknowledge what went wrong.

21. Our NHS Complaint Standards say an effective complaint handling system makes sure staff take a thorough, proportionate and balanced look into the issues raised in a complaint. It gives people fair and open answers to their questions based on the facts and takes full accountability for mistakes identified.

22. From our review of the complaint responses, the Provider provided a response in line with our standards. It appropriately reviewed the scans and concluded that there was a left sided cyst. It provided a thorough and balanced look at the complaint by having the scans reviewed again and by comparing her scans with her later scans to consider the differences. As we have seen evidence the scans were reported correctly, it was appropriate for the Provider to come to this conclusion in its response to the complaint. Therefore, we would not investigate the complaint handling any further.

23. In its complaint response on 3 July 2024, it said the explanation for the contradicting findings in Miss L’s scans is that these are not pathological ovarian cysts, rather they are normal ovarian follicles which form during a menstrual cycle and then disappear by resolving on their own.

24. Miss L says this explanation is incorrect as she is post-menopausal and does not have a normal menstrual cycle.

25. Our adviser disagreed with the Provider’s explanation for the contradictory reports as Miss L is post-menopausal. They did say the Provider were correct in reassuring Miss L about the contradictory reports.

26. Our adviser referred to the cyst radiography guidance to assist in our decision making. This says in post-menopausal women, a sub 3cm simple cyst can fluctuate, decrease and increase in size and can disappear and appear again. We understand this would explain the contradictory scans Miss L had. The RCOG guidance says research showed simple cysts below 5cm disappeared in 53% of women. Considering the advice we have received and relevant guidance, simple cysts can disappear in post-menopausal women which likely explains the contradictory findings between Miss L’s scans at different times.

27. We are sorry the Provider provided incorrect reasoning for the contradictory scans. We recognise how this has caused further distress for Miss L, and contributed to her doubt around whether she received a correct diagnosis.

28. In its response on 29 August 2024, the Provider said it reviewed this again as Miss L was not post-menopausal and it noted that ovarian cysts can develop and resolve over time for a variety of reasons which will explain the difference between the scans.

29. Our internal policy says we can deliver an answer or outcome for a complaint that resolves the complaint they have brought to us. It says we can resolve a complaint through our own explanation of what has happened.

30. We acknowledge the Provider gave an incorrect explanation for Miss L’s different scan reports. We are sorry for the further distress, confusion and doubt this caused Miss L about her diagnosis. The Provider provided further clarification about this, and we have expanded on this with a further explanation for the difference in scans which we think resolves Miss L confusion about the difference in scans. We think this further information remedies any confusion she experienced as a result of the incorrect information in the response.

31. In conclusion, we cannot criticise the Provider for not acknowledging the failing as we did not find evidence of a failing in our investigation. However, we do recognise part of the complaint response gave Miss L incorrect information which caused further distress and confusion. We have provided a further explanation to reassure Miss L, and we think this resolves Miss L’s confusion about the contradictory findings in her scans. We will not investigate this further.

1. We have carefully considered Miss L’s complaint about the Provider. We are sorry to hear Miss L has experienced on going pain. We recognise how her different scan reports have caused confusion and distress about her diagnosis.

2. From our consideration of the complaint, we have not seen evidence that the Provider incorrectly reported her scan on 20 March 2024. We think it appropriately reported the scan, and we have explained our reasons why. We hope our further explanation of why this happened will reassure Miss L that her care was appropriate.