A 41-year-old mother with terminal breast cancer was let down by her hospital who failed to detect and treat her cancer, an investigation has found.
The mum-of-one, identified only as Ms G, was referred to West Hertfordshire Hospitals NHS Trust’s breast clinic.
At her follow-up appointment in May 2010 the breast specialist failed to undertake the appropriate tests to rule out cancer, the Parliamentary and Health Service Ombudsman investigation found.
When Ms G returned to the breast clinic in December 2011 biopsies revealed she had advanced inoperable breast cancer and secondary cancers of the liver, brain and bone.
The Ombudsman’s report found that had Ms G’s cancer been detected and treated in 2010, her prognosis would have been much better and the cancer would unlikely be terminal.
Ms G has lived with the distress of suffering from a terminal illness for more than a-year-and-a-half.
She lives with constant uncertainty about how much time she has left with her son, who she is bringing up alone.
Trust chief executive Samantha Jones said: “We clearly failed Ms G and I have offered her my personal and sincerest apologies, and I have offered to meet with her.”
Ms G felt too unwell to work because of the intense treatment regime and lost her job, causing her further anxiety as her financial situation deteriorated.
Parliamentary and Health Service Ombudsman Julie Mellor said: “A 41-year-old mother has had her life cut short because of the serious failings by West Hertfordshire Hospitals NHS Trust to carry out the necessary tests to rule out breast cancer.
“They missed vital opportunities to diagnose the cancer and begin treatment.
“This is a very sad example of what can go wrong when doctors and Trusts don’t carry out the necessary and proper diagnoses and tests, and the terrible impact it can have on someone’s life.
“Doctors and hospitals must understand and learn from complaints.
“There needs to be a cultural shift in the NHS where staff are encouraged to be open when things go wrong and to admit to mistakes.
“Only when listening and learning are truly embedded into an organisation’s culture will we see the improvements we need for a better and safer NHS for all.”
The health ombudsman also discovered the breast specialist failed to make her aware of the importance of attending the follow-up appointment.
The Trust failed to tell Ms G about the potentially serious cause of her condition, the importance of attending her next appointment and inappropriately discharged Ms G without making her, or her GP, aware of the seriousness of her situation.
The Parliamentary and Health Service Ombudsman’s key recommendations are:
– The Trust pays Ms G £70,000 for the pain, suffering, additional medical treatment and distress over a lengthy period caused by the service failure and the exasperation produced by the way it handled her complaint. The Trust has already done this.
– For the Trust to give Ms G a full and sincere apology.
– There should be processes in place to ensure that if a risk has been identified, appropriate measures are taken to protect patients.
– Trusts must have mechanisms in place to review patients like Ms G to ensure they are made aware of the importance of attending their appointments and to manage their discharge appropriately.
– The Trust agrees to share information about the Ombudsman’s investigation with the second doctor’s current employer so she has a further opportunity to learn from this complaint.
Ms Jones said: “We accept in full all of the recommendations and they have acknowledged that we have made the necessary changes to help prevent this type of incident, which dates back to 2010, from happening again.
“This includes providing enhanced training for doctors to recognise, diagnose and test for cancer.”
Ms Jones said the Trust has also undertaken a major review of all of its cancer services which includes:
– The implementation of a new information system to track each patient’s care.
– Weekly meetings to proactively review the overall management of all referrals and appointments.
– Retraining and better supervision of staff.
Ms Jones said: “In addition, we have changed the way we inform patients about the importance of attending follow-up appointments and how we ensure patients, as well as their GPs, are aware of the seriousness of their condition.”
Martin Ledwick, head cancer information nurse at Cancer Research UK, said: “You should see your GP if you feel you have symptoms or have any changes to what is normal for you.
“If your symptoms persist it’s important to continue to seek help.”
For further questions about cancer, you can call one of the Cancer Research UK nurses free on 0808 800 4040 9am to 5am Monday to Friday or visit Cancer Research UK’s website at www.cancerresearchuk.org