Treatment delayed by Trust's failure to diagnose

What happened

Mrs A's GP referred her to the Trust in spring 2012. After staff saw her in the emergency assessment unit, she had gynaecological surgery for an infected cyst.

During the operation, the surgeon asked for a consultant's help. Although the findings at surgery were not typical of this type of cyst, clinicians diagnosed a long-standing infection in the cyst and removed as much as possible. Test results, which were available to staff several days after the operation, did not show any cyst tissue; this should have prompted staff to question the original diagnosis.

After surgery, Mrs A returned to her GP because the wound was not healing. Staff from the Trust's gynaecology outpatients department saw her in summer 2012. They sent her for a scan, which showed she had an uncommon, complex anal fistula (a fistula is an abnormal opening between two parts of the body). In late summer 2012, staff referred Mrs A to the Trust's surgeons who specialised in treating the lower digestive system, and she had two more operations.

Mrs A was concerned about the delays in diagnosis and treatment so she sent the Trust a written complaint. After it investigated, the Trust did not acknowledge that there were any failings in Mrs A's care.

Mrs A was unhappy about the Trust's responses at the local resolution meeting, so she brought her complaint to us.

What we found

There was service failure because the Trust missed several opportunities to diagnose Mrs A's anal fistula. Consequently, there were significant delays to her treatment. We upheld the complaint.

The Trust did not acknowledge any failings in Mrs A's care after its complaint handling process. This added to Mrs A's distress, because she felt very embarrassed when she had to discuss her symptoms.

Although Mrs A's fistula was treated, she still has slight anal incontinence. However, we could not directly link her symptoms to the delay in her diagnosis and treatment because we think the complex nature of her fistula and the necessary surgical treatment are more likely reasons for this.

Putting it right

The Trust apologised and paid Mrs A £750 for the failings in her care that led to delays in treatment, and for her distress.

The Trust prepared an action plan that described how it would make sure that it has learnt the lessons from the failings identified by this complaint, and how it would avoid similar failings in future.