16. When we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen. We have done this and have not found any indications that something has gone wrong.
Change of plan
17. Mrs N complains that the Trust changed the previously agreed plan for her July 2023 breast surgery on the day of surgery. The Trust says it provided the surgery agreed in June of that year.
18. Mrs N had an appointment with Trust surgeons in April 2022. The follow up letter sent to her and her GP explained that further surgery was planned with the aim of making Mrs N’s right breast a similar shape to the left. The letter explained that the best way to do that would be to release and re-suture (re-sewing) the existing scar on the right breast and undertake some lipofilling to it. In addition, there was to be liposuction of the outer left breast and fat harvested from elsewhere, likely Mrs N’s flank, being added to the right breast. There seems to be no dispute surrounding this appointment.
19. Mrs N’s records show that she had a further appointment in June 2023. The Trust says that this was an in-person appointment and contemporaneous notes recorded for it say that the aim of the pending surgery was to ‘improve her symmetry and remove the excess tissue laterally to her left breast’. They say the surgeon was ‘very clear that she will not be able to make her right breast the same size as her current left breast’ but said she would ‘endeavour to improve the quality of breast tissue and size of the right breast’.
20. Mrs N says there was only one appointment and discussion about her reconstructive surgery. Based on the information and evidence provided, we can see the second appointment and discussion did take place. We are mindful that Mrs N has undergone numerous appointments and surgeries for a variety of reasons over the past few years. This has undoubtedly been difficult, stressful and potentially confusing. Mrs N told us when asked that she could not recall specific dates of appointments but does remember having them and that these were documented.
21. The records of this appointment reflect that there was more than one member of staff present with Mrs N. They refer to the surgeon, a breast reconstructive Clinical Nurse Specialist and a doctor working within the surgeon’s clinic being present during the appointment. There are references to matters specific to Mrs N noted, such as the emphasis on not being able to make the right breast the same size as her left and her desire to have an implant on the right to increase its size.
22. Additionally, a follow up letter sent to both Mrs N and her GP confirmed the plan that was noted as being agreed during this appointment, albeit not until after the surgery happened. Collectively, we think this adds weight to this consultation having taken place as the Trust claims.
23. Our advisor explained that the difference between the plans referred to in the April 2022 and June 2023 appointments was that there was no mention of the potential for lipo-harvesting from somewhere other than Mrs N’s left breast in the second of these. There does not seem to be any reason noted for this. That said, the aim of the surgery was the same. Neither consultation mentions that surgery would guarantee Mrs N’s breasts would be a particular size. The aim was to ‘improve symmetry’ or make them a ‘similar shape’.
24. Mrs N signed a consent form on the same day as her surgery in July 2023. She says this was for something different than she had agreed to previously. We acknowledge that the outcome of the surgery was not what she expected and that she is waiting to have further surgery to remedy this.
25. The signed consent form states the plan was to ‘re-do breast reduction and liposuction’ on the left and some revision of the scar and breast mound on the right side. Our advisor explained that this gives a wide scope for the surgery. There is no specific mention of lipofilling the right side, only revision of it, although this could include lipofilling. There is no change from the previous notes for the plan for the left side.
26. GMC’s Guidance ‘Decision Making and Consent’ explains that the patient should be given the opportunity to consider their choices and make an informed decision. It does not specify how long this period should be and this can be variable. It would usually be expected that any change of plan would be detailed on the patient’s medical record with reasoning for this and the details of the discussion with the patient about this. Our advisor explained that this is good practice rather than something which clinicians are obliged to do.
27. Mrs N’s complaint is that she was unaware of the revised plan until the day of surgery. Based on what we have seen, we believe she was told about this in the June 2023 appointment. Mrs N had a period after the June appointment until the July surgery to consider what was discussed. So, the Trust gave her time to consider it, in line with the GMC guidance.
28. The notes made during the consultation are reflected in the follow up letter the Trust sent to Mrs N and her GP. Usually, if a patient felt that a confirmation letter did not accurately reflect the consultation itself, we would expect them to raise this. In Mrs N’s case, however, she did not have the opportunity to do this. Because there was such a short period between the June appointment and the July surgery, the letter was not generated and sent until after Mrs N’s operation took place. While we think this is a shortfall, in that it would have been helpful for Mrs N to have seen this before her surgery, it is not substantive enough to be considered a failing.
29. This is because we think that even if Mrs N had received the letter before her surgery, it is unlikely to have changed what happened. We know that, aside from the June appointment, Mrs N was reminded there was a change on the day of the surgery. Mrs N was asked whether she knew what surgery she would be having and, when she referred to the plan from April 2022, was told by the surgeon that this was not the case.
30. While we appreciate that being given this information, which Mrs N believed to be new, on the day of planned surgery may not be ideal, the surgeon did not demonstrate any failing in this regard. There is no requirement for changes to be communicated a certain amount of time in advance.
31. The operation records show the left breast was reduced and the right revised, including having some lipofilling to it. This was essentially the same procedure noted on the consent form and reflects the June 2023 plan. Although there was no reference to the lipofilling, the ‘revision’ it did refer to could include action like this.
32. We acknowledge that Mrs N is deeply unhappy with the outcome of her surgery and understand why this is the case. Having considered this part of her complaint in detail, we do not think there has been any failing for us to investigate further.
Pressured to consent
33. Miss N complains that she felt pressured into agreeing to something she did not want without the opportunity to properly consider the new plan.
34. As referred to previously, GMC’s Guidance says the patient should be given the opportunity to consider their choices and make an informed decision.
35. Mrs N says she was upset when the surgeon told her on the day of her operation that they planned to do something different to what she expected. She says the surgeon told her that if she was not in agreement with that they would need to move on to other patients. In response, Mrs N says she told the surgeon to ‘do what they wanted’.
36. There was no obligation for Mrs N to consent to the surgery if she felt this was not what she was expecting or wanted – or for any other reason. The surgeon also told Mrs N that she was able to leave if she was unhappy with the plan. This shows the Trust gave Mrs N options and there was some time for her to consider the next steps.
37. We acknowledge that Mrs N did not want to have to wait any longer for the reconstructive surgery given how long she had already waited. We also understand that emotions were high on the day and that the reconstruction was very important to Mrs N. Ultimately, Mrs N was given chance to step back from the surgery and decide whether she needed more time to consider the plan before making that decision.
38. Mrs N confirms she provided consent – both verbally to the surgeon and in writing on the consent form she signed. The surgery was then completed and we do not think there is any failing on the Trust’s part in this regard. There is no evidence that it tried to persuade Mrs N to consent, or that it acted improperly in allowing her to make the decision. While we recognise her distress with the result of the surgery she received, we are mindful that this was conducted in accordance with her agreement to do so.
39. We recognise the difficulties Mrs N has experienced and the upsetting impact. We wish her well for the further surgery she has planned.