Decision Report 201404294

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.