12. Mrs A believes the cancer was present in February 2017 and the Trust failed to diagnose it, or perform further investigations, despite an existing symptom.
13. The Trust says it followed all processes correctly. It says it does not automatically recall people for further assessment if they report a current symptom at the screening appointment. The Trust will only recall people for assessment if the mammogram shows abnormal features. The assessment scale used is a standardised classification for breast imaging in the UK published by the British Society of Breast Radiologists (BSBR) with the Royal College of Radiologists. The Trust says all seven of their radiologists assessed the 2017 mammogram images as category 1 (negative). This is a normal test result, and it would not trigger an automatic recall for further investigation.
14. When looking at whether there have been failings in the service provided, we consider what should have happened in the circumstances. We look at what did happen and consider whether it fell so short as to be a failing. If we see evidence of failings, we consider whether the claimed impact can be linked to those failings.
15. In order to decide what should have happened, we asked our clinical adviser. They told us there is always variability among radiologists when assessing imaging, including mammograms. As a result, less distinct findings on an image may not be seen, or may be dismissed by one radiologist as unimportant, yet seen as requiring attention by another. Either assessment may end up being the most appropriate. This means, to a certain extent, the images are open to interpretation. Having viewed the images in this case, our clinical adviser was surprised all seven radiographers at the Trust held the same view.
16. Our adviser reviewed the initial screening mammograms from 2017 at a dedicated mammography workstation. They categorised the mammograms as category 2 (requiring recall and further assessment). They explained they would categorise the images as category 2, rather than category 1, because they saw a faint asymmetric (non-symmetrical) soft tissue density lying posteriorly (towards the back) and centrally on the right craniocaudal (a standard view taken from above during routine screening mammography) in the right breast. We recognise our adviser had the benefit of hindsight when analysing the mammogram, but note the site of the finding matches the site of the cancer diagnosed in 2019.
17. Although the soft tissue density does not indicate definite malignancy (cancer), in line with the 2017 NHS Breast Screening Programme Guidance for Mammographers, it does meet the standard for recall for further assessment. The NHS guidance is in turn based on the Quality Assurance Guidelines for Mammography provided by the National Quality Assurance Coordinating Group for Radiography from 2007, which were still in operation in 2017.
18. Mammographers are not trained or expected to be able to examine patients in the screening setting, or to give clinical advice. But page nine, bullet point four of the guidance says, ‘any significant symptoms reported by women are to be recorded’. The mammographer should note down on the clinical sheet and the computer system important or relevant symptoms, which should be seen by the person reporting on the images at the time of reporting. Mrs A told us she reported a lump at the time of attending for the screening mammograms, and explained to staff it was causing her discomfort. Her daughter also remembered it clearly because she was acting as a translator. She told us the service said if they found anything, they would say so in the letter they would send.
19. We are satisfied Mrs A reported a lump. We have looked at the evidence, and there is no note of symptoms recorded in the information provided. We therefore consider the radiographers were not in possession of all the relevant information when they made their assessment.
20. Our view is there were failings by the Trust mammographers in not noting the patient had reported a lump on the computer and report sheet. The result was the radiographers did not have access to all the information available. The Trust did not do everything it could have done with the information it had. If the radiographers had been provided with this additional knowledge, this could have influenced the way they interpreted the mammogram.
21. In summary, we know our adviser would have categorised the mammogram as requiring recall. Mrs A likely informed the Trust she had a lump. Mrs A went on to develop a malignancy in the same breast/area.
22. We asked our adviser, if Mrs A had been recalled in 2017, what likely clinical tests/assessments the Trust would have done. Our adviser explained a recall would involve a physical examination of the breast, very likely an ultrasound scan if there was a palpable lump or other abnormal finding, and then a repeat mammogram. If this revealed an abnormality, doctors would have performed a biopsy.
23. Mrs A told us, she cannot stop thinking that if the Trust had identified the cancer earlier, her treatment and the impact on her life would have been less.
24. To explore a possible injustice, we consulted again with our adviser. They explained it is not possible to say for certain what the impact would have been if doctors had reassessed Mrs A in 2017. Although the asymmetric soft tissue density described above lies in the general area of the later malignancy, it does not necessarily represent early malignancy.
25. Neither is it possible to say for certain whether a clinical examination would have found a breast lump. Although Mrs A suspected one, it is quite common that patients’ reported breast lumps turn out to be nothing abnormal on assessment and investigation.
26. But it is also possible that, if the Trust had recalled Mrs A for assessment, doctors would have found a lump on examination. If so, further ultrasound or mammography screening could have led to a biopsy and diagnosis of the breast malignancy at a much earlier stage.
27. If this had happened, Mrs A’s treatment could have been less invasive, and there could have been a much reduced impact on her long-term health when compared with the later diagnosis. For instance, the risk of metastatic spread would have been considerably reduced.
28. We have weighed up the evidence and our view is, if the Trust had documented in Mrs A’s notes that she had presented with concerns about a lump in her breast, this may have influenced the way the radiologists viewed her mammogram results, and they may have changed their categorisation and the decision not to list her for recall.
29. The Trust deprived Mrs A of the opportunity for further assessment by not recalling her in 2017. While we cannot say with certainty her treatment would have been less extensive, the distress of not knowing this is ongoing for Mrs A. This injustice is linked to the Trust’s failure to record her reported lump and its follow-up decision to not recall her.
30. As the Trust has not recognised its failings, it has not taken steps to put things right. Based on our Principles for Remedy (our principles), where there have been failings leading to an injustice, the public organisation should try to offer to put things right, in order to return the complainant to the position they would have been in, if the failings had not happened. Paragraph 59 of our principles says an appropriate range of actions should include: an apology, explanation and acceptance of responsibility; action to put things right, for example, service improvements to minimise the risk of something happening again; also, payment in recognition of the injustice suffered.
31. In order to decide on the right level of financial compensation, we use our scale of injustice to consider the impact on the person. If it is not possible to return them to the position they were previously in, an organisation should make an appropriate payment. When deciding on a financial payment, we also refer to past payments we have made in similar circumstances.