Inadequate investigations did not amount to 'cover up'

What happened

Mrs D had a mammogram and was told that it was 'normal'. Seven months later she was diagnosed with breast cancer. She asked the Trust whether there had been a mistake in reading the mammogram. The Trust did an Interval Cancer Review, but did not pass the results of this on to Mrs D. This was because the doctor who was going to give them to her misunderstood Mrs D's request and made a mistake when gathering information.

Mrs D complained to NHS England as she had lost faith in the Trust's ability to provide a response. NHS England arranged for an independent review of the mammogram and a meeting to discuss Mrs D's concerns. Mrs D was given the review report at the start of the meeting and told to read it when she got home.

When read in conjunction with what NHS England said to Mrs D about her concerns, the report seemed to suggest that something had gone wrong with the interpretation of the mammogram. Understandably confused, Mrs D complained to us as she wanted a final, clear explanation of what had happened.

What we found

It was understandable that Mrs D felt something was being covered up when the Trust did not respond to her request for further information. However, the fact that they did not respond was due to a misunderstanding and error on the part of one individual. This was unfortunate, but it was not service failure.

To help us decide whether the responses were appropriate, we took clinical advice, which showed that the cancer was visible – with hindsight – on the original mammogram. But the abnormality that could be seen was very unclear and is the sort of thing that is sometimes overlooked.

NHS England initially made good attempts to resolve Mrs D's complaint by arranging for an independent review of her mammograms followed by a meeting to discuss her concerns. However, its good work was somewhat undone when it did not get a copy of the independent review report to give to Mrs D before the meeting. This meant that, when she read the report after the meeting, Mrs D was left with unanswered questions that could have been but were not discussed at the meeting. This was upsetting for Mrs D as she continued incorrectly, but understandably to believe that an error had been made and covered up.

Putting it right

NHS England wrote to Mrs D, acknowledging the failings identified, and apologising to her for the injustice she suffered as a result of those failings.