Cancer specialists at Crosshouse Hospital failed to spot an ‘abnormality’ in a woman’s breast scan that developed into stage three cancer two years later.

Rosemary Agnew, the Scottish Public Services Ombudsman (SPSO), has upheld a complaint by the woman against the NHS Ayrshire and Arran board.

She ruled that health staff should have identified ‘calcification’ that was apparent in a scan taken in 2019 and would have enabled an early diagnosis of breast cancer.

Ms Agnew also said she did not believe that the board had learned lessons from what happened.

The Ombudsman also took the board to task over their initial claim that they had spotted the issue in 2019 but had decided it did not merit further investigation.

The patient, identified only as ‘C’ in the SPSO report, had a family history of breast cancer and had been referred to the high risk/family history service at Crosshouse Hospital for monitoring.

There she had regular mammogram scans for potential early signs of breast cancer.
When one scan of an abnormality was identified in the woman’s left breast in 2019, it was investigated.

The symptoms turned out to be a cyst. A scan of C’s right breast taken at the same time was reported as ‘normal’.

However, two years later it was revealed that the scan of her right breast had in fact shown an abnormality.

NHS Ayrshire and Arran said that mammogram scans are reviewed by two consultant radiologists or consultant radiographers who report independently to ensure there are two clinical opinions.

They claimed said that the abnormality had been spotted and decided that it was not ‘sinister’ enough to merit a biopsy.

An expert adviser to the Ombudsman said that there was no evidence of the abnormality or any discussions in the patient’s medical records.

The Ombudsman’s report said that the board subsequently stated that they were talking about 2021 rather than 2019.

The board claimed that, even if the abnormality been identified in 2019, the malignancy wouldn’t have necessarily been picked up.

However, the adviser said that this form of cancer did not change from benign to malignant and that it would have been identified had the abnormality been picked up.

The patient had also complained that she had been led to believe the review of her case would be independent, rather than the internal procedure that took place.

While the adviser to the Ombudsman suggested the board was ‘reasonable’ in its decision to carry out an internal review, they said that the conclusions reached were ‘not reasonable’.

Ms Agnew concluded: “I found that the board failed to provide reasonable care and treatment to C as abnormalities were missed in 2019.

“Therefore, the opportunity for early diagnosis was missed.

“I do not consider that the board demonstrated they have learned from what happened in this case.

“I found the medical records did not support the board’s response.

“On seeing a draft version of this report, the board clarified that the abnormalities were not identified or discussed in 2019, and that they were referring to a meeting that was held in 2021.”

Dr Crawford McGuffie, NHS Ayrshire and Arran Medical Director, said the service fully accepted the SPSO position.

He said: “I am sorry that we did not meet the high standards of care that we strive for in NHS Ayrshire and Arran for this patient.

“We have issued a formal apology to patient C, and are working through the
necessary changes to our complaints responses and our governance processes that are detailed in the report.

“We will ensure that we share the learning from the report within the organisation and will share the findings from these reports with staff, in particular with those responsible for the operational delivery of the service and with our clinical governance teams.”