Failure to carry out appropriate tests meant breast cancer went undetected until it was too late

What happened

Ms G saw her GP in spring 2010 because she was concerned about changes she found in her breast. The GP suspected mastitis but sent an urgent referral to the Trust to rule out the possibility of anything more sinister.

Breast clinic staff saw Ms G quickly. They carried out an ultrasound scan and a clinician diagnosed mastitis. The clinician arranged a follow‑up appointment for three weeks later. Unfortunately Ms G was unable to get to this appointment and went to the clinic again in early summer 2010.

At this second appointment, a different clinician again diagnosed mastitis. The clinician arranged a three‑month follow‑up appointment for Ms G, which she did not attend. The same clinician wrote to Ms G later that year, discharging her from the service.

In autumn 2011 Ms G went to her GP again because she was concerned about changes in her breast. Her GP referred her back to the Trust, which diagnosed advanced breast cancer that had spread to her bones, liver and brain. Ms G was told that her cancer was terminal and although treatment was available to prolong her life, the cancer was now incurable.

What we found

The first appointment was conducted appropriately. It was reasonable for the first clinician to diagnose mastitis. The clinician arranged follow up and noted that if the condition did not clear, then further tests should be carried out at the follow‑up appointment.

There were failings at the second appointment. Staff should have carried out a mammography, a biopsy or both, but this did not happen. A clinician discharged Ms G from the service with no advice about the potential seriousness of her condition and what she should do if her symptoms did not clear. The Trust gave Ms G and her GP a false sense of reassurance about Ms G's condition when it wrote to Ms G twice with a diagnosis of mastitis.

There were also failings in the way the Trust handled Ms G's complaint. It did not fully investigate and its response did not acknowledge the extent of the failings or their impact on Ms G.

Ms G's cancer would have been detectable in 2010 and the Trust could have diagnosed it at an early stage when Ms G's prognosis would have been much better. It was likely the secondary cancers developed as a result of the failure to diagnose breast cancer.

Putting it right

During the investigation, the Trust gave us details of changes and improvements to its services since the events occurred. We are satisfied that how it monitors patients on the cancer pathway has improved significantly.

The Trust apologised to Ms G and its chief executive offered to meet Ms G to apologise in person for the failings we identified.

The Trust paid Ms G £70,000 for the distress, pain and suffering caused by the failings we identified.

We also shared information about this complaint with the General Medical Council because we were concerned that the second clinician's failure to carry out appropriate tests may present a risk to patient safety.

The full report on our investigation is available to read on our website.