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North Bristol NHS Trust

P-003270 · Report · Decision date: 21 January 2025 · View Bristol NHS Trust scorecard
Complaint (AI summary)
Mrs L complained the Trust incorrectly recorded she declined a breast screening, didn't send a further invitation, and failed to amend her medical records after her cancer diagnosis.
Outcome (AI summary)
Partly upheld. The Trust failed to amend Mrs L's medical records as promised. A letter to her and her GP to address this was recommended.

Full decision details

The Complaint

3. Mrs L complains after she contacted the Trust prior to her breast screening appointment in March 2020, it incorrectly recorded that she declined to attend and did not send her a further invitation. She is also concerned it has not acknowledged it made an error and has not apologised or taken action to address the issue she raised.

4. Mrs L has since been diagnosed with stage 3 breast cancer with advanced localised spread. She says treatment has had a significant impact on her daily life and her surgeon believes a mammogram in 2020 would have identified the cancer.

5. Mrs L would like the Trust to acknowledge its failings and apologise. She also wants it to correct her medical records as it said it would do, and ensure other patients who missed screening appointments due to the COVID-19 pandemic are recalled.

Background

6. The NHS website explains NHS breast screening uses X-rays, called mammograms, to look for cancers that are too small to see or feel. Anyone registered with a GP as female will be invited for NHS breast screening every three years between the ages of 50 and 71. Anyone aged 71 or over is not automatically invited but can ask for appointment.

7. Mrs L was 69 years old when the Trust sent her an invitation for breast screening. The screening was due to take place on 27 March 2020.

8. In mid-March, the government began making announcements about COVID-19 restrictions. Mrs L telephoned the Trust on 19 March. The first lockdown was announced on 23 March and measures legally came into force on 26 March.

Findings

Contact with the Trust 11. Our Principles of Good Administration say organisations should aim to ensure that service users are clear about their entitlements, about what they can and cannot expect from the public body, and about their own responsibilities.

12. Mrs L’s account is that she ‘proactively rang the breast screening service [on 19 March 2020] to ask if the [27 March] appointment would be going ahead and due to the public health situation re covid I was told not to come, to which obviously I agreed. I was given the impression that another appointment would be sent once the covid situation improved but no appointment ever came.’

13. Mrs L says the Trust recorded that she declined to attend her appointment. The Trust said this is not what happened. It told us it made a note on the system that she did not want to attend at that point in time.

14. We can see there is limited information available in the National Breast Screening System records. The ‘status’ of the appointment is ‘Cancelled (client)’ and a ‘comment’ alongside says ‘Other corna [sic] virus Phone 19/03/2020’. The Trust said it notified Mrs L’s GP she did not want to be screened at that time.

15. It said it was following national guidance which meant Mrs L was not sent a further invitation for screening. It said for anyone who cancelled their own appointment, the onus was on the individual to recontact the programme if they wished to make another appointment.

16. The Trust highlighted all clients that had their appointment cancelled by the programme were put into a holding clinic and re-invited when the programme restarted. It said Mrs L cancelled her appointment before national guidance was provided.

17. There is a fundamental disagreement about how the cancellation came about. There is no dispute Mrs L contacted the Trust or that she had concerns about the pandemic. What we cannot be certain about is exactly what was said during the telephone conversation on 19 March.

18. The Trust told us those who chose to cancel their own appointments prior to 27 March were advised to contact it once the COVID-19 situation had improved. It has acknowledged it was unlikely to have known a date at that time.

19. The Trust said from 27 March, it was given the guidelines to cancel people and put them into holding clinics. It said this was national guidance, and a process was implemented to ensure that all people in holding clinics were re-invited once the screening programme restarted. In its complaint response, it told Mrs L this happened on 6 July 2020.

20. We know Mrs L believed she would not be eligible for screening once she turned 70, in August 2020. The Trust’s website at the time said ‘In line with the Government’s new rules to help reduce the spread of infection, we have paused routine breast screening appointments. We will reschedule appointments as soon as it is safe to do so.’

21. Appendix 1 of the NHS technical guidance covers rescheduling routine screening. It said for women in group 6, who have been invited but have not attended or chosen to cancel ‘Do not re-appoint at this time. Suspend second timed appointments. Episodes to be left open and appointments to cancelled with a comment of ‘COVID-19’. The guidance notes ‘Consideration for further action required for this group at a later stage ahead of screening resuming.’

22. The Trust told us the group 6 guidance does not relate to Mrs L’s situation as she contacted the programme before this guidance was issued. We checked this with NHS England. It confirmed Mrs L was not in this cohort and may have fallen outside of the cohort of women affected by the COVID-19 pause.

23. NHS England said ideally, Mrs L she should have been advised to reschedule by contacting the service. If the entry on the system was closed, a repeat offer would not have automatically been generated for a future invitation. It said there was no national guidance prior to 27 March so services would have agreed their own response to queries locally.

24. The Trust’s complaint response said with hindsight, the screening service could have put Mrs L in the holding clinic even though her appointment was not recorded as being cancelled by the Trust. This suggests there may not have been a consistent approach in place.

25. Based on the evidence we have seen, we cannot say the Trust should have put Mrs L in a holding clinic. As it seems the Trust was broadly acting in line with what NHS England expected, we have not identified a failing. We recognise Mrs L may not share this view. Understandably, she considers it a potential missed opportunity.

Action following complaint 26. Mrs L is concerned the Trust has not acknowledged it made an error and has not apologised or taken action to address the issue she raised. As we have explained, we have not identified a failing in the approach the Trust took. However, we looked at whether the Trust acted in line with our Complaint Standards when considering the concerns.

27. We know the complaint was prompted by Mrs L obtaining her records from her GP Practice. When she saw what the records said, she asked the Practice to amend them. In its complaint response, the Trust said the Breast Screening team had adjusted her record and this would be visible on the records her GP received in late February 2024.

28. Our Complaint Standards say organisations should provide prompt, appropriate and proportionate remedies. The Trust’s adjustment to the records would have reflected this.

29. We contacted the Practice to check if this happened as Mrs L could not see that her records had changed. We understand the Practice contacted the Trust directly about rectifying Mrs L’s records in mid-February 2024.

30. We appreciate the Trust’s perspective that it is unable to update the GP Practice database and has no direct access to its patient management system. It also told us it has no evidence of a call or email from the Practice itself about updating Ms L’s records. We have no reason to doubt the Practice’s account regarding this.

31. It appears the Trust sent nothing further to the Practice and it did not respond to its query either. This was not in line with our Complaint Standards. It is clear this has added to what was already a concerning experience for Mrs L, causing her to lose trust in the Trust.

32. The Trust said in hindsight, it would have been ideal if it had contacted the Practice to ensure that its requested change had been actioned. It apologised this did not happen. We are making recommendations in relation to this issue, as it seems the Trust can help to resolve this situation.

33. Overall, we are therefore partly upholding the complaint. We hope this, and our investigation, will give Mrs L some reassurance about her experience and we would like to wish her well with her recovery.

Our Decision

1. We were very sorry to hear about Mrs L’s diagnosis and we understand why she is concerned her cancer should have been identified sooner. We have been unable to conclude the Trust did not follow the right process after Mrs L’s call in the early days of the COVID-19 pandemic.

2. We hope it is clear this is not intended to diminish Mrs L’s experience. We have not seen evidence the Trust did take the action it said it would after the complaint. We can see the Trust’s original entry was distressing for Mrs L and not being able to see an amendment added to Mrs L’s concerns. We therefore partly uphold the complaint and recommend it writes to Mrs L and her GP Practice to address this.

Recommendations

34. In considering our recommendations, we have referred to our ‘Principles for Remedy’. These state that where poor service or maladministration has led to injustice or hardship, the organisation responsible should take steps to put things right.

35. With that in mind, within six weeks of the date of this report, the Trust should write to Mrs L (with a copy to us) to acknowledge the failing we have identified and apologise for the impact this had on her. It should explain how it will liaise with her GP Practice to ensure the change to her records has been completed successfully. If it can, it should explain why the change has not been visible so far.

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