WIREDGOV

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 by The Parliamentary and Health Service Ombudsman has found.

The mum-of-one, Ms G, was referred to West Hertfordshire Hospitals NHS Trust's breast clinic and at her follow-up appointment in May 2010 the breast specialist, failed to undertake the appropriate tests to rule out cancer.

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 Parliamentary and Health Service 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, and lives with constant uncertainty about how much time she has left with her son, who she is bringing up alone. She 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 also 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.

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 our investigation with the second doctor's current employer so she has a further opportunity to learn from this complaint

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-5am Monday to Friday or visit Cancer Research UK's website at www.cancerresearchuk.org"

Read the report: 'Hospital fails to diagnose breast cancer’

Notes to editors

1. For further information please contact Ben Miller in the press office on 0300 061 4324 ben.miller@ombudsman.org.uk If you are calling out of hours please contact 07825 781 289.
2. The Parliamentary and Health Service Ombudsman was set up by Parliament. It is the final step for people to complain to when they have been treated unfairly or received a poor service from the NHS in England or a government department or agency. Its role is to investigate complaints fairly, without taking sides and make recommendations to put things right, to prevent the same problem from happening again. Its powers are set out in law and the service is free for everyone. In 2013/14 it investigated 2,199 cases compared to 384 the previous year. The majority (80%) of its investigations were about the NHS.