Source · SPSO (Scottish Public Services Ombudsman)

Grampian NHS Board

SPSO (Scottish Public Services Ombudsman) Partly Upheld Reference 201406815 Sector Health Category clinical treatment / diagnosis Decided 01 December 2015

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Full decision

Summary

Miss C complained regarding the care and treatment she received for a benign breast lump in 2011. In 2014, Miss C was diagnosed with breast cancer. The board said that the lump had been benign in 2011 and it was very unlikely that a benign lump becomes cancerous. Miss C said that she had not been provided with adequate follow-up or advice, and that the lump had become malignant. Miss C said the board should accept this was possible and that the lump should have been removed in 2011. Miss C also complained of an excessive delay in providing her with radiotherapy.

We took independent advice from one of our advisers, who is a consultant oncologist. Our adviser said there was no evidence to show benign lumps could become malignant. It was possible that despite the appropriate tests being carried out and the results from these showing no sign of cancer that it had in fact been malignant in 2011. Our adviser said that this did not constitute an unreasonable standard of care. However, the delay in the provision of radiotherapy was unreasonable, since it had breached Scottish Government targets and the board had been unable to provide evidence that they were taking steps to prevent a reoccurrence.

We found that the board had acted reasonably in 2011, both in terms of the tests carried out and the decision not to remove the lump from Miss C's breast at this time. When further tests in 2014 showed it to be malignant, the lump was appropriately removed, but the board unreasonably failed to provide radiotherapy within Scottish Government targets, so we made a recommendation about the delay.

Recommendations

We recommended that the board: provide evidence that the review being conducted into radiotherapy provision has addressed the delays experienced in this case.

Related reading

View Decision Report 201406815 as a PDF (12.37 KB) Updated: March 13, 2018

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