Trust suggested removing patient's ovaries when this was not clinically necessary

What happened

Ms J was diagnosed with breast cancer, for which she received clinical treatment at the Trust. Ms J questioned whether that treatment was enough to avoid her subsequently developing secondary cancer.

After the treatment, Ms J said, the nursing team did not manage her side effects, which caused her unnecessary pain and distress.

Staff then told Ms J that it was necessary to remove her ovaries because of a non–malignant mass not connected to her cancer. She questioned this decision via a second opinion, which concluded that the removal of her ovaries was not clinically necessary.

When Ms J complained to the Trust, it delayed giving reasonable explanations to all the points she raised, so she complained to us.

When we asked the Trust for clinical records so we could investigate the aspects of Ms J's complaint, the Trust had mislaid the records. Therefore we were unable to reach firm conclusions about some aspects of the complaint.

What we found

The treatment Ms J received for her breast cancer met the expected standards at the time, and the Trust's explanation of this was reasonable. There was no evidence that its actions would cause Ms J to develop secondary cancer unnecessarily.

The nursing care after treatment was inadequate, and caused Ms J avoidable suffering. The Trust failed initially to fully recognise those flaws.

There was no clinical need for Ms J's ovaries to be removed, and staff did not take relevant considerations into account when they decided on the treatment plan.

The Trust's handling of Ms J's complaint was unacceptably delayed and incomplete, and its loss of clinical records indicated systemic failures in the records management process.

Putting it right

The Trust agreed to audit its records management system and to give a written explanation of the actions it took to remedy the flaws we found.

It agreed to take action to make sure there was no repeat of the nursing flaws we found, and to give Ms J an explanation of the action it had taken.

The Trust agreed to arrange further training for the clinicians responsible for the decision to remove Ms J's ovaries, and to make sure that its future actions to treat ovarian cysts are in line with recognised guidance.

The Trust also agreed to pay Ms J £250 in recognition of its poor complaint handling and the loss of her clinical records, and to give her an explanation of the improvements it has made to its complaint handling service.