3. Mrs A complains that on 20 June 2022 the Trust failed to do a biopsy (taking a small sample of tissues or cells for examination) on a lump on her neck after an ear, nose and throat (ENT) doctor requested it on 7 June.
4. She says the Trust finally did a biopsy in October and confirmed she had incurable breast cancer that had spread to her thorax, abdomen and neck.
5. Mrs A would like a financial payment and for the Trust to accept it was wrong not to dot the biopsy in June 2022.
6. Mrs A had been diagnosed with breast cancer twice before, this had been treated and she had been given the all-clear.
10. On 24 May 2022 Mrs A found a lump on her neck. She saw her GP the same day who made a referral to the ENT department. On 7 June she attended her ENT appointment, and the doctor referred her to the radiology department at the Trust for a biopsy.
11. At the appointment on 20 June the Trust consultant did an ultrasound examination but did not think a biopsy was needed. Mrs A says the consultant insisted there was nothing to worry about because they could tell it was not cancer. They planned for her to return for a check-up on the lump in three months’ time.
12. On 2 August Mrs A attended an ENT appointment and they again referred her to radiology for an ultrasound and biopsy. At this appointment the Trust again told her no biopsy was needed.
13. On 3 October Mrs A had an ultrasound at the Trust. She says the consultant advised her there had been no changes in the glands in her neck, but it agreed to complete a biopsy to ‘put her heart at rest’.
14. On 11 October she had a phone call to attend an ENT appointment on the same day. At that appointment the Trust told her the biopsy showed she had metastatic breast cancer (cancer that has spread from where it started to another part of the body).
15. The NICE guidance says that if a person presents with a suspected neck lump, doctors should assess the clinical features to try to find the cause. They should ask about where the lump is, the size and growth, any changes and how long it has been there. The guidance says:
• congenital and developmental lumps are often present at birth and may get bigger rapidly after a mild upper respiratory tract infection. They can also appear in adulthood and increase in size over a longer timescale • persistent or rapidly growing neck masses (for example present for more than six weeks) are more likely to be malignant (cancerous) • a lymph node diameter greater than 3 cm (30mm) may be a sign of malignancy • lymph node metastases are more likely to have a short history with progressive increase in size.
16. The NICE guidance also says doctors should assess other risk factors for malignancy, such as smoking, excess alcohol use, betel nut use (chewing a nut that is popular in Asia and the Pacific), previous history of head and neck cancer or irradiation (exposure to radiation) or history of Hashimoto's thyroiditis (increased risk of lymphoma).
17. The records show that when Mrs A was referred to the Trust it noted her previous history of breast cancer. Previous history of breast cancer is not listed in the NICE guidance as a risk factor for malignancy and she had none of the other risk factors listed. Mrs A had the neck ultrasound on 20 June 2022. At this time there were no other reported symptoms, only that the lump had progressed to three lumps by this point. She had felt the left neck nodes for one month.
18. At the examination on 20 June the neck nodes were also small, with the largest being 9mm. Our adviser told us a lymph node is not considered to be enlarged until it is over 10mm. They explained lymph nodes (or glands) can enlarge when they are fighting off infection, are inflamed from an autoimmune disease like rheumatoid arthritis, or have had cancer or lymphoma cells lodged in them. The appearances of both are different, although sometimes small nodes can look normal. From looking at Mrs A’s medical records we can see there is a very detailed description of the lymph nodes in the first ultrasound report, and our adviser confirmed there were no signs of anything worrying. Importantly, the NICE guidance suggests lymph nodes greater then 30mm may be a sign of cancer. On 20 June Mrs A’s largest lymph node was 9mm, which is much smaller than the size the NICE guidance says should prompt suspicion of cancer.
19. We therefore do not uphold the complaint as the Trust did not act outside of NICE guidelines when deciding not to do a biopsy when the referral was first made by ENT in June 2022.
20. Our decision is in no way intended to undermine the incredibly difficult time Mrs A went through. We understand the devastating impact her diagnosis had on her and her family. We also know it must be upsetting to wonder whether things could have been different if tests had been done sooner.
21. While it does not form part of our decision, we want to share with Mrs A what our adviser said about an earlier biopsy. They said a biopsy earlier in the year would not have changed things for her. Sadly, her cancer is incurable and an earlier biopsy and treatment would not have led to a different outcome. We hope knowing this may bring some comfort to her.
1. We do not uphold this complaint. This is because Mid Yorkshire Hospitals NHS Trust (the Trust) did not act outside of relevant guidelines when treating Mrs A.
2. We are sorry to hear about the circumstances that led Mrs A to complain and we understand the impact these events had on her and her family.