A practice in the North Yorkshire area

6. Ms C complains about aspects of the care and treatment provided by the Practice on 9 October 2023.

7. Specifically, Ms C complains the Practice did not appropriately consider her concerns about a breast lump that had increased in size, a change in breast size, and pain in the breast area. Ms C says the examining doctor dismissed these concerns as being due to an ill-fitting bra but should have instead referred her to the breast screening service.

8. Ms C explains she was later diagnosed with breast cancer following a routine mammogram in August 2024, and she later underwent an elective mastectomy of the left breast (a surgical procedure to remove one or both breasts to significantly reduce the risk of developing breast cancer). Ms C feels that the failure to refer her in October 2023 led to a delay in her cancer diagnosis and a delay in starting treatment.

9. She says the failure to act on her symptoms has also caused her prolonged her pain and discomfort.

10. Ms C says as a result of the above, she has lost faith in the Practice’s care, and these events have had a significant and lasting physical and mental health impact.

11. Ms C is seeking an apology, an acknowledgement of the impact of the failings in her care, and service improvements.

12. Ms C attended the Practice to seek advice in respect of a lump in her left breast which had swollen and was becoming painful.

13. Ms C’s regular GP examined her breast and advised that no abnormality was present. The GP advised they felt the pain was being caused by the underwire element of her bra, which was ill-fitting.

14. On 16 August 2024, Ms C attended a regular mammogram (a low-dose X-ray examination of the breasts) appointment at a specialist breast screening unit at a local hospital. This noted a mass in the upper quadrant of Ms C’s left breast. Further scans and surgery confirmed this mass to be a Grade 2 Invasive Lobular Carcinoma. This is a type of breast cancer that originates in the lobules (milk-carrying ducts) of the breast.

15. After discussing the options available, Ms C elected to have a total mastectomy of her left breast on 14 October 2024. A total mastectomy involves the surgical removal of the entire breast, including breast tissue, nipple, areola and skin, primarily to treat or prevent breast cancer.

16. After the surgery, Ms C made an official complaint to the Practice regarding the advice she was given, the failure to make a referral to a breast screening service, and the manner of the doctor involved. Ms C remained unhappy with the Practice’s response as she felt more action could be taken to ensure these concerns did not affect other patients. She therefore brought her complaint to us on 7 April 2025.

19. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the event complained about had a negative effect which the organisation has not put right. Having done so, we have found the Practice accepted there were gaps in its care and has agreed to take action to address this.

Issue 1 – Failure to Refer to Breast Screening Service

20. The NICE guidance ‘Breast cancer - recognition and referral’ recommends clinicians should refer people using a suspected cancer pathway referral for breast cancer if they are aged 30 and over and have an unexplained breast lump with or without pain.

21. At the time of the appointment, Ms C was over 30 and reported to her GP a lump in her left breast which was causing her concern.

22. Ms C says her GP should have referred her for further investigations at the appointment on 9 October 2023. She feels an early opportunity to assess her lump and quickly progress her cancer diagnosis was missed at this appointment. We are very sorry to hear this has led her to losing trust in medical staff. We recognise this was an incredibly difficult and distressing time for Ms C.

23. In its response letter of 18 December 2024, the Practice confirmed the GP could not feel a lump during their examination on 9 October 2023. This is in keeping with what they recorded in the clinical records. Sadly, there are no other medical records, or any other sources of evidence available, to help us determine on balance, whether a lump was present at this time. We are left with two different accounts from Ms C and the GP about what her symptoms were.

24. It is important to explain our role is to make independent final decisions about NHS complaints in England. We make decisions by weighing up and considering all the available evidence. We then consider the likelihood that something has gone wrong with the service provided. As we are impartial, we must make robust decisions based on facts and evidence. Regrettably, without further evidence we are not able to reach a view on whether something likely went wrong at this appointment. For this reason, we consider a formal investigation would not be practical for this complaint.

Issue 2 – Dismissive attitude of examining Doctor

25. The GMC guidelines say:

‘You must provide a good standard of practice and care. If you assess, diagnose or treat patients, you must: • adequately assess the patient’s conditions, taking account of their history (including the symptoms and psychological, spiritual, social and cultural factors), their views and values; where necessary, examine the patient • promptly provide or arrange suitable advice, investigations or treatment where necessary • refer a patient to another practitioner when this serves the patient’s needs.’

26. Ms C has advised that during her appointment, the examining doctor was rude to her and dismissive of her presentation, this added up to a difficult conversation.

27. We appreciate Ms C was unhappy with the examining doctor’s attitude. We have considered Ms C’s account carefully. We do not discount Ms C’s account. We have attributed equal weight to what she told us and what the Practice said.

28. Regrettably, there does not appear to be independent evidence to help us form a view on what happened. Ms C’s medical records do not tell us how the doctor behaved. We have nothing to confirm the details of the interaction, only a complainant and a doctor who have differing views on how the conversation was perceived.

29. We have considered Ms C’s account of her conversation with the GP. We can understand how she may have felt she was not taken seriously, especially as she would have been really worried about her health.

30. We have carefully considered the evidence. We do not think we can say what is more likely to have happened. We do not think a detailed investigation would give us more independent evidence to base a finding on. In these circumstances, we do not think an investigation would be practical or provide a satisfactory conclusion. Based on this, we do not think we should take any further action on this issue.

31. In the response to the complaint, the Practice says the doctor ‘understands your visit to the surgery that day did not meet your expectations and is truly sorry for how this made you feel. She recognises how important your concerns are and what you've been through since your diagnosis. An analysis of your complaint will be completed and taken forward.’ We cannot see how we would be able to obtain anything further for Ms C’s concerns, and so we will close this matter.

Conclusion

32. Our ‘Principles for Remedy’ list a range of outcomes in response to a mistake, which include ‘an apology, explanation and acknowledgement of responsibility’. Our ‘Principles for Remedy’ also say to seek continuous improvement, the organisation may make changes, including staff training, to ensure poor service is not repeated.

33. In its complaint response of 21 October 2025, the Practice apologised for what happened and accepted it had contributed to Ms C’s distress. It provided a detailed explanation of what went wrong and accepted that it made mistakes. The Practice also explained it had made several improvements to make sure future referrals were dealt with properly and similar issues did not arise. These new procedures are:

• All clinicians have been reminded of the importance of ensuring that every aspect of a consultation is clearly documented in the patient’s notes • Clinicians have been reminded to ensure that patients are provided with clear explanations for all decisions made during consultations, including where referrals are not indicated • Longer appointments are being booked when patients present with more than one issue, to allow sufficient time for discussion and understanding • As part of the yearly appraisal process, all GPs are encouraged to reflect on their practice and do a review of any complaints.

34. Having reviewed these actions, we consider the Practice has analysed the incident and taken measures to reduce, or even prevent, a similar issue. We feel the evidence shows the Practice has learned from the incident and made robust improvements to stop this happening again. It has also apologised, taken responsibility and explained what happened in its response to Ms C. We think this is in line with our ‘Principles for Remedy’.

35. We have not found any impact on Ms C that has not been put right. We can also see the Practice appears to have acted in line with our ‘Principles for Remedy’ by apologising and making service improvements. We will therefore take no further action on this point.

36. We thank Ms C for bringing her complaint to us. We understand this was a very difficult time for her. We are glad to see the Practice has put measures in place to prevent the same issue happening again as a result of her complaint.

37. While we know this may not be the decision Ms C wished for, we hope this report clearly shows how we have reached our decision and reassures that her complaint has led to improvements in the issues she faced whilst a patient at the Practice.

1. We have carefully considered Ms C’s complaint about the Practice. Ms C says opportunities were missed to make an earlier referral to the local breast screening service.

2. Ms C says she was later diagnosed with breast cancer and needed significant surgery. She wonders if this might have been avoided had her cancer been diagnosed sooner. We recognise the significant impact these events have had on Ms C.

3. We can see the Practice has acknowledged it should have referred Ms C sooner to the local breast screening service. In bringing the complaint to us, Ms C told us she would also like the Practice to acknowledge the impact these events have had on her, provide an apology and make service improvements to ensure that another patient does not suffer as she has through this period.

4. We have spoken to the Practice and it has agreed to provide a further response to address these outcomes.

5. We consider the Practice’s proposed actions are appropriate to resolve the outcomes Ms C is seeking. We therefore do not see indications to suggest further action is needed. We explain this in more detail below.