Summary
Mrs C, who is an advice worker, complained on behalf of Mrs A about the care and treatment she received at Caithness General Hospital in 2004/05 for a lump in her breast. In August 2013, Mrs A had a routine mammogram and was referred for further tests, after which she was diagnosed with breast cancer in the area that had been examined in 2004/05. Mrs A was concerned about the lack of communication by the surgeon in 2004/05 in relation to some test results which indicated an abnormality. She also complained that a procedure for exploring whether there was any sign of malignancy (cancer cells) was not properly performed; that she was wrongly advised that the lump would never be cancerous; and that she should have been kept under continual review.
The board found no failings in the treatment given in 2004/05. However, they acknowledged that there were failings by the surgeon in the record-keeping of one of her procedures, and that there was a lack of evidence that the results of a test which indicated an abnormality (but not malignancy) had been explained to her.
We took independent advice on this case from one of our medical advisers. We found that Mrs A was given appropriate investigations in accordance with national guidance in place at the time. However, we were critical of the poor record-keeping by the surgeon and the failure to explain all of Mrs A's test results. Therefore, we upheld this aspect. We did not identify evidence to support that Mrs A was given misleading information about the lump and, even though there was an abnormality in one of the tests, this was not a reason to keep her under continual review.
Recommendations
We recommended that the board: share with the surgeon the importance of ensuring test results are fully explained to patients and provide evidence that informed consent has been obtained where relevant.
Related reading
View Decision Report 201404294 as a PDF (12.48 KB) Updated: March 13, 2018