Communication 22. NICE guidance on breast cancer management says at 1.15.4 ‘ensure all people who have had treatment for breast cancer have an agreed, written care plan, recorded in their notes’. It says the plan should include signs and symptoms to look out for and seek advice on.
23. NLM information mentions guidance from American Society of Clinical Oncology, for breast cancer surveillance. Our adviser confirmed this is relevant guidance.
24. It suggests explaining to patients the most common spots of recurrence of breast cancer. The symptoms are ‘lumps or bumps anywhere but especially on the breast or chest wall – bones that hurt without trauma, especially the spine or hips – headaches out the ordinary – shortness of breath, especially if receiving tamoxifen (a type of drug used to treat breast cancer) – leg swelling, especially if receiving tamoxifen’.
25. The records show that Mrs R had a telephone appointment with an advanced nurse practitioner at the Trust on 16 September 2020. The appointment took place following her breast cancer treatment.
26. During the appointment, Mrs R reported feeling well. Mrs R had a right breast mammogram, which came back unchanged. The Trust then added her to its remote breast cancer surveillance programme. The programme meant it would recall Mrs R for mammograms yearly, until she had completed five years.
27. We have found nothing in the records to show that the Trust gave Mrs R advice on the symptoms to look out for, following her cancer treatment.
28. The Trust acknowledged in its response letter that it did not arrange an end-of-treatment consultation with Mrs R. It said it did not remind Mrs R of the symptoms of disease recurrence. It explained this was likely due to the pandemic, which led to cancelling some appointments and its clinics were reduced.
29. We consider this an indication of a failing, as the Trust did not follow the guidance noted above. We will explore the impact of this later in this report.
Monitoring 30. NICE guidance on breast cancer management says at 1.15.1 ‘offer annual mammography for five years to all people who have had or are being treated for breast cancer’.
31. The Trust arranged for Mrs R to have yearly mammograms. During Mrs R’s appointments between September 2020 and November 2023, there is no evidence within the records that she reported any concerns during her appointments.
32. Our adviser helped us understand that Mrs R’s mammogram results were normal and indicated no sign that her cancer had returned during this time. Their view, which we agree with, is it is likely Mrs R’s metastatic breast cancer began suddenly between November 2023 and April 2024.
33. Miss U is concerned her mother reported back pain to the GP, which may have indicated her cancer returned. She is concerned the Trust should have monitored her better, and it could have detected cancer earlier.
34. The GP records show that Mrs R reported symptoms such as aching legs in May 2022. An MRI scan of the spine showed degenerative disease (conditions causing the gradual, progressive deterioration of tissue or organ structure and function. It is often linked to aging, genetics or lifestyle). In July 2022, Mrs R complained of abdominal pain which the GP treated with antibiotics for a urinary tract infection. This then cleared following treatment.
35. Mrs R had routine blood tests at the GP Practice in December 2022, December 2023 and 15 January 2024. Our adviser helped us understand the blood test results did not indicate Mrs R’s cancer had returned.
36. Our view, on the balance of probabilities, is Mrs R’s secondary cancer developed between November 2023 and April 2024. This is because the latest mammogram result from November 2023, was normal. We consider there is also nothing in the GP records to suggest it developed earlier than this.
37. We think the Trust adequately monitored Mrs R. It arranged yearly mammograms, in line with NICE guidance above. The guidance does not mention any other tests which should be performed. We therefore will not take any further action on this.
38. We recognise Miss U’s concerns caused her and her family significant distress. We do not wish to underestimate how difficult this time was for them. We hope our decision can provide some reassurance.
Impact 39. We consider there is an indication of a failing, as the Trust should have informed Mrs R of the symptoms to look out for post cancer treatment.
40. Miss U says her mother was unaware the symptoms she had (such as back pain), was a symptom to look out for. Miss U is concerned her mother’s cancer was not detected as early as it could have been. This is because her mother would have likely sought medical advice, if she had known. She has concerns it led to her dying prematurely.
41. Frontiers in Oncology’s review found no evidence a remote surveillance programme had any effect on overall survival. We consider this indicates it is unlikely there was any clinical impact on Mrs R.
42. NICE guidance on breast cancer management recommends yearly mammograms. We can see that the Trust arranged this. As outlined earlier in our report, the results do not indicate that her cancer had returned.
43. We have not found any indication Mrs R reported concerning symptoms during this time, which the Trust did not act upon. For example, we have found no mention of her reporting back pain to the Trust.
44. We think it is likely Mrs R’s cancer returned between November 2023 and April 2024. The Trust was not due to review Mrs R again until November 2024.
45. Our adviser’s view, which we share, is there is no evidence that the sad outcome would have changed.
46. Miss U also explained due to this, her and her family experienced significant distress. We think it caused distress to them, as they would have been concerned about the care Mrs R received, at an already difficult and distressing time. We are sorry to hear how this impacted them.
Remedy 47. As an outcome of her complaint, Miss U is seeking service improvements and financial redress.
48. Our service model guidance sets out how we consider cases. It says, at 3.59 ‘resolution means delivering an answer or outcome for a complainant that resolves the complaint they have brought to us’.
49. Our Principles for Remedy are reflected in the NHS Complaint Standards. This says organisations should offer fair remedies to put things right and identify learning and use it to improve services.
50. The Trust already provided some service improvements as a result of Miss U’s complaint. It said the clinic has now re-introduced end-of-treatment appointments and provide patients with information regarding what to expect from their follow up care and any symptoms to look out for.
51. We approached the Trust to ask if it could provide evidence of the above. We asked it to provide an action plan on how the Trust has, or is going to, ensure the same thing does not happen again. It has agreed to do this. We will ask it to do this within three months of the date of this statement.
52. We asked the Trust to consider a financial remedy to Miss U. To assist us in considering an appropriate level of financial remedy, we used our severity of injustice scale (our scale). We also review similar cases where the person has experienced a similar impact.
53. Level two on our scale covers instances where there are ‘minor failures in communication which caused a small degree of distress or worry against a background of bereavement’.
54. We consider this appropriately reflects the impact on Miss U. This is because they had concerns following Mrs R’s death, that the outcome could have been different, if they were informed of the symptoms to look out for. We think this added to her and her family’s bereavement.
55. We approached the Trust to ask if it would consider providing a resolution to Miss U in line with this. It has agreed to provide a financial remedy of £300 in keeping with level two on our scale. We will ask the Trust to make this payment within one month of the date of this statement.
56. At section 3.60 of our service model guidance, it says ‘it is for us, and not the person bringing the complaint to us, to decide whether the actions taken have resolved the complaint’. We consider the above actions from the Trust are sufficient to resolve Miss U’s complaint.
Conclusion 57. We thank Miss U for bringing her complaint to us. We are truly sorry to hear about this difficult time and offer our sincere condolences on the sad loss of Mrs R.
58. We hope Miss U can be reassured that the Trust has taken steps to ensure it has learnt from this and provided an appropriate remedy. We also hope it provides some reassurance that we think the Trust appropriately monitored her mother.