Greater Glasgow and Clyde NHS Board - Acute Services Division

Summary

C complained on behalf of their child (A) that the board had failed to provide A with reasonable care and treatment for a Phyllodes tumour (a tumour of the breast). C complained that A was told that they had a benign (non-cancerous) Phyllodes tumour when this was not the case. A later found out that the tumour had been malignant (cancerous). C also said that A was not offered radiotherapy (a treatment using high-energy radiation) or chemotherapy (a treatment where medicine is used to kill cancerous cells) following the Phyllodes tumour diagnosis, and that A was not appropriately monitored following the diagnosis.

We took independent advice from a consultant breast surgeon. We found that A was appropriately monitored following the diagnosis and it was reasonable that A was not offered radiotherapy or chemotherapy in the circumstances.

However, we also found that the clinic letters following A's surgery did not describe the Phyllodes tumour as malignant, and the size of the malignant Phyllodes tumour had not been documented in the multidisciplinary team notes. We upheld C's complaint on this basis.

Recommendations

What we asked the organisation to do in this case: Apologise to A for failing to communicate reasonably with them regarding the Phyllodes tumour being malignant and for failing to record the size of the malignant Phyllodes tumour in the multidisciplinary team notes. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

What we said should change to put things right in future: Patients should be informed about the type of Phyllodes tumour identified and such discussions should be clearly documented.

The size of malignant Phyllodes tumours should be clearly documented in multidisciplinary team notes.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Related reading

View Decision Report 201908577 as a PDF (26.95 KB) Updated: January 20, 2021