Report Date


Case Against

A GP Practice in the area of Aneurin Bevan University Health Board


Clinical treatment outside hospital; GP

Case Reference Number



Upheld in whole or in part

Ms B complained about the care and treatment provided by a GP Practice in the area of Aneurin Bevan University Health Board. She complained that when she presented at the Practice on 11 June 2020 with a lump in her left breast, she was reassured that it was a benign cyst that required only monitoring. When she re-presented on 22 September, concerned that the lump had grown, she was examined by a different GP who, without any obvious means of comparison, assured her that the lump had decreased in size. When she informed the Practice on 14 December that the lump had increased in size and that she had detected a second lump in her left armpit, it was 3 February 2021 before she was seen by a breast specialist. Ms B complained that contrary to established guidance, GPs failed to make this referral under the appropriate urgent suspected cancer (“USC”) pathway.
The Ombudsman found that the care provided at the consultation of 11 June was below an adequate standard as a referral should have been made at this point, under the USC pathway. This caused a significant injustice to Ms B as, had her cancer been diagnosed at this time, she could have been counselled against becoming pregnant and avoided being in the difficult and avoidable position whether to delay cancer treatment to complete her pregnancy or to have a termination. Similarly, had referral and diagnosis been made sooner, she may have elected to accept a short delay in treatment to pursue the option of harvesting her eggs with a view to using them in the future for IVF. This aspect of the complaint was therefore upheld.
The investigation found that the care provided at the consultation of 22 September was below an adequate standard as there was a failure to properly record the size of the lump identified and because there should have been an USC referral this aspect of the complaint was upheld. The Ombudsman found that the USC referral made on 14 December was appropriate and in accordance with the USC pathway and this aspect of the complaint was not upheld.
The Practice agreed to implement the Ombudsman’s recommendations to, within 1 month, provide Ms B with a written apology for the failings identified and pay Ms B redress in the sum of £1000 in recognition of the avoidable pregnancy termination and the loss of opportunity to harvest her eggs prior to commencement of chemotherapy. The Ombudsman also recommended that the Practice undertake a Significant Event Analysis of the care provided to Ms B on 11 June and 22 September 2020 and that, within 2 months of the completion of the Significant Event Analysis, it should hold a learning event for relevant clinical staff regarding the importance of comprehensive recording of the findings of physical examinations and adherence to the NICE NG12 guidance on cancer referrals.
3 August 2023