Hull University Teaching Hospitals NHS Trust

5. Ms B complains about the care and treatment provided to her by Hull University Teaching Hospitals NHS Trust (the Trust) when it undertook investigations into a lump in her breast from April – December 2023.

6. Ms B complains that the Trust:

• failed to report on a small lump in her breast following an April 2023 mammogram and told her that there was no lump present • should have investigated the lump further in July 2023 when she told them it had grown and that she now had yellow discharge coming from her nipple • incorrectly reported that she was examined in her September 2023 appointment and that the lump had not grown • incorrectly reported what was discussed in the ‘being open meeting’ in its notes.

7. In December 2023 Ms B attended the Trust again as the lump was continuing to grow. The discharge from her nipple was tested, and it was explained that she likely had breast cancer. In January 2024 it was confirmed that she had breast cancer. Ms B is undergoing treatment for this which was due to end in December 2025.

8. Mrs B feels that had she been examined appropriately at the September 2023 appointment, her breast cancer could have been diagnosed sooner and some of the extensive treatment she has received could have been avoided.

9. She also says that this has had an impact on her mental health, as she worries about other women in her family who are susceptible to cancer, and the treatment they may receive in the future.

10. Mrs B would like the following to remedy her complaint:

• a financial remedy • service improvements • clarity about what went wrong in her care • a being open meeting report that accurately reflects what was discussed.

11. On 28 April 2023 Ms B had a mammogram. She says that the Trust failed to report on a small lump that was shown on her breast.

12. In June 2023 Ms B said that the lump on her breast had increased in size, and that she was now experiencing yellow discharge from her nipple. Ms B went back to the Trust on 10 July 2023 for further investigations into this. Ms B explained that she was told that this was ‘fibrocystic changes’ and not to worry about it.

13. On 4 September 2023 Ms B had a clinic appointment at the Trust. Ms B explained that her lump had significantly grown, but the Trust recorded in her medical records that there was no palpable lump at this appointment. Ms B told us that she was not examined at this appointment. Ms B also told us that she was later told by the Trust that she should have been offered further diagnostic testing after this appointment, however she was not, as the testing only yielded diagnoses in 5% of women.

14. In December 2023 Ms B returned to the Trust again. The discharge in her nipple tested positive for blood and the lump had grown significantly. Ms B explained that she was sent for an ultrasound, which showed suspicious changes and so she then had a biopsy of her breast.

15. In January 2024 Ms B was diagnosed with breast cancer. She had a mastectomy (surgery to remove the breast) and lymph nodes removed. Ms B has since been receiving chemotherapy and radiotherapy.

19. 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.

April 2023 Mammogram

20. Ms B had a mammogram on 28 April 2023. Ms B told us that following the appointment the Trust told her that there was no evidence of any lumps on her scan. Ms B explained that following her making a complaint, the Trust told her that there was a small lump visible on this mammogram, and that it should have referred Ms B for more investigations following her appointment.

21. In the notes of the meeting that Ms B had with the Trust on 5 April 2024, the Trust explained that two radiologists reviewed the images from Ms B’s April 2023 mammogram and deemed that no further action was necessary on the basis of these.

22. Ms B feels that there was evidence of a small lump on her mammogram, and that the Trust should have investigated this further at the time. Ms B feels that if this had been done, her cancer could have been diagnosed sooner, and she could have avoided the need for some of the extensive treatment that she has had to have.

23. Ms B’s medical records show that she attended an appointment for a mammogram on 28 April 2023. Our radiography adviser explained that Ms B’s mammogram showed that she had mixed moderately dense breast tissue, that was more prominent in her upper right breast.

24. Our radiography adviser explained that asymmetry of breast tissue, such as that shown on Ms B’s mammogram, is not uncommon. They told us that although this can sometimes be an indicator of breast cancer, Ms B’s breast density was spread out across her breast, and did not collect around one specific point, as it does when it may be an indication of potential breast cancer.

25. Our radiography adviser explained that there are no other features on the mammogram that raise suspicion of a potential cancer. This, alongside the type of breast density that Ms B had, meant that there was nothing of significance on the mammogram that should have been reported, or meant that Ms B needed any further investigations at this time.

26. The NHS information on breast screening explains that if a mammogram result shows no signs of breast cancer no further tests will need to be done and a person will be invited for a screening again in three years if the person is between 50 and 71.

27. At the time of Ms B’s mammogram she was 53, meaning that as the mammogram was clear, there was no necessity for Ms B to be recalled to the Trust for further investigations.

28. Therefore, we consider the Trust correctly advised Ms B that her mammogram was clear, and in line with the NHS information, she was advised she would be recalled for a mammogram in 3 years’ time. There are no indications that the Trust needed to do any further investigations on the basis of Ms B’s mammogram result.

July 2023 appointment

29. Ms B explained that in June 2023 she noticed that she was having discharge coming from her nipple and could feel a lump in her breast. Ms B attended an appointment at the Trust on 10 July 2023 to have these symptoms investigated.

30. Ms B told us that she feels that the Trust should have done more to investigate these symptoms than it did.

31. In its complaint response dated 1 July 2024, the Trust explained that when Ms B attended the Trust for her appointment in July 2023 there was no visible nipple discharge present, and so it was unable to consider performing any tests on it. It explained that regardless, clinicians do not routinely test nipple discharge.

32. It said that it performed an ultrasound on Ms B’s breast, and that there was no indication of any cancer but it showed that Ms B had some cysts in her breast. It explained that it therefore scheduled Ms B to be reviewed in 6 weeks.

33. The records show that on 10 July 2024 Ms B attended an appointment at the Trust as she had been referred there by her GP due to her having concerns about a lump in her breast, and discharge coming from her nipple.

34. The records show that on examination, it was identified that Ms B had a tender lump on her right breast, beside her nipple. The records explain that Ms B had been experiencing discharge from her nipple, however there was none present at this examination.

35. Ms B had an ultrasound of her breast at the appointment, and this showed ‘fibrocystic changes’ (fibrous tissue and cysts in the breast) and that there was nothing suspicious on her scan. It advised Ms B to keep a record of the instances of nipple discharge, and to return if anything changed.

36. Our oncology adviser explained that it is important not to ‘traumatise’ the nipple, in order to force it to produce discharge, as this can make symptoms worse. They advised that the Trust gave Ms B the appropriate ‘safety netting’ advise by telling her to keep a record of the instances of nipple discharge and to return to it if anything changed.

37. Our oncology adviser said if a patient has had a mammogram within the last six months that was clear, it would not be necessary for the mammogram to be repeated.

38. The GMC guidance says that clinicians should ‘adequately assess a patient’s conditions taking account of their history, including their symptoms’.

39. Our oncology adviser said an ultrasound was an appropriate investigation at the time due to the clear mammogram she had had less than three months earlier. They said no further investigations were necessary based on the result of the ultrasound.

40. In line with the GMC guidance, we consider the Trust appropriately investigated Ms B’s ongoing symptoms, by performing an ultrasound scan and considering the recent mammogram. It also advised her to return to it if any of her symptoms changed. We have therefore not seen any indications of failings in the way that the Trust treated Ms B at her July 2023 appointment.

September 2023 appointment

41. Ms B told us that in September 2023 she attended the Trust again for an appointment with it. Ms B explained that the lump in her breast had grown significantly but that the records of this appointment noted that there was ‘no palpable lump’ in her breast. Ms B told us that she was not examined at this appointment.

42. Ms B explained to us that she feels that this contradicts her July 2023 appointment notes, as these notes record that there was a lump in her breast. She also said that she does not understand how the Trust can say that there was ‘no palpable lump’ in her breast, when she was not physically examined at this appointment.

43. The clinic letter from Ms B’s September 2023 appointment shows that the consultant examined the breast and found no palpable lump and that the nipple looked normal. She was offered a duct excision during the appointment. The records show that Ms B declined this procedure due to the potential side effects.

44. Therefore, the Trust says it examined Ms B but Ms B says she was not. We have considered the information provided by Ms B and the information provided by the Trust and feel that we would not be able to reconcile the differing accounts. Although this does not mean that we do not believe Ms B’s account, we do not feel there is sufficient evidence to allow us to make a decision on the balance of probabilities if she was examined at the September 2023 appointment or not.

45. Ms B feels that the Trust offering her a duct excision at the September 2023 appointment shows that the lump was present, as it would not have offered her any treatment or surgery if there was no palpable lump.

46. Our adviser explained to us that a duct excision is a procedure where milk ducts are removed from the breast. This procedure can be used as a way to treat repeated nipple discharge, such as in Ms B’s case, or to evaluate for potential malignancy. Our adviser explained that a duct excision is a way to treat nipple discharge, rather than a procedure to remove the lump from Ms B’s breast.

47. We discussed with our adviser if the lump being present at the July 2023 appointment would necessarily mean that it would also be present at the September 2023 appointment. Our adviser explained to us that lump palpability in breast cancer cases can fluctuate and be more difficult to identify on some occasions. They said that the documentation of a lump at the July 2023 appointment does not necessarily mean that it will have been palpable in September 2023.

48. Given that the procedure that Ms B was offered was to treat her nipple discharge and that breast lump palpability can fluctuate, we do not feel that we can say whether the lump in Ms B’s breast was definitely present at her September 2023 appointment. We do recognise that the Trust and Ms B have differing accounts of what happened at the appointment.

49. As there are two conflicting accounts of what happened here, and there is no further evidence we can gather to help us reach a decision, we consider that we would not be able to reach a satisfactory conclusion so there would be no value in taking this forward for further investigation. Therefore, we will not be looking into this matter further.

Meeting notes being inaccurate

50. Ms B told us that on 5 April 2024 herself and her partner attended a ‘being open’ meeting with the Trust to discuss her concerns about the care that she received.

51. Ms B said that she does not feel like the notes that the Trust provided to them from the meeting accurately report what was discussed and that it missed out a lot of information from it.

52. Ms B explained to us that in this meeting the Trust told her that she was a carrier of the BRCA2 gene mutation. A carrier of the BRCA2 gene will have a significantly increased risk of breast cancer and a slight increased risk of ovarian cancer. Ms B explained that this was concerning to her as she has two daughters, who therefore may also have the gene.

53. Ms B told us that she feels that this news was told to her suddenly and without sympathy or a clear discussion about this from the Trust. Ms B does not feel that the meeting notes accurately reflect the way that this information was discussed with her.

54. The records show that the Trust had a meeting with Ms B on 5 April 2024 in which it discussed with her concerns that she had about different aspects of the treatment she had received for her breast cancer.

55. The records also show that it told Ms B that she had the BRCA2 gene, told her that her daughters should discuss this with their GP’s, and told Ms B that it would contact her to discuss this further once she had digested the information that it had given her.

56. We do not have any further evidence which confirms what was actually discussed in the meeting. Ms B told us that the original meeting notes have been shredded and the meeting was not recorded.

57. As we were not present during the meeting, and as there was no recording, we would not be able to reach a conclusion about whether the notes from the meeting are an accurate reflection of what was discussed.

58. Although this does not mean that we do not believe Ms B’s account, we do not feel there is sufficient evidence to allow us to make a decision on the balance of probabilities if the meeting notes are accurate or not, or if the way that the Trust told Ms B that she had the BRCA2 gene was appropriate.

59. We understand that it will be stressful for Ms B to feel that the meeting notes are not an accurate representation of what was discussed. As there are two conflicting accounts of what happened here, and there is no further evidence we can gather to help us reach a decision, we consider that we would not be able to reach a satisfactory conclusion so there would be no value in taking this forward for further investigation. Therefore, we will not be looking into this matter further.

60. We would like to thank Ms B for taking the time to bring her complaint to us. We recognise that she has had difficult experiences whilst under the care of the Trust. We would like to wish her all the best for any ongoing treatment she may receive.

1. We have carefully considered Ms B’s complaint about Hull University Teaching Hospitals NHS Trust (the Trust). We would like to thank Ms B for taking the time to bring her complaint to us. We understand that it will have been distressing for her to feel that her cancer could have been diagnosed sooner than it was.

2. After consideration, we have found no evidence that anything went seriously wrong in Ms B’s treatment at the Trust.

3. We have seen no evidence that the results of Ms B’s mammogram in April 2023 needed to be investigated further. We also consider the Trust offered Ms B the correct advice and treatment at her July 2023 appointment.

4. Due to differing views on what happened at the September appointment, we cannot say if Ms B was examined or not, and we cannot make a decision on what was said at the being open meeting that Ms B had with the Trust on 5 April 2024. As such, we will not be investigating this complaint any further.