Decision Report 201402666

Summary

Mrs C complained about the care and treatment she received at Glasgow Royal Infirmary in relation to breast reconstruction following a bilateral mastectomy (surgical removal of both breasts). Mrs C was concerned that her choice of reconstruction was interfered with by the specialist breast reconstruction nurse, that the medical choice of expander breast implants was inappropriate, and that the nurse who had inflated the implants had overfilled them, which led to additional treatment and surgery to address the problems.

During the board's investigation of the complaint, they identified the need to implement a protocol for the inflation process. However, they did not clearly acknowledge to Mrs C that the nurse had overfilled the implants well above the manufacturer's recommended guidelines.

We took independent advice on this case from two of our advisers, one of whom is a specialist surgeon in breast reconstruction and the other a specialist nurse. We did not find evidence to clearly show that Mrs C's decision about reconstruction options was unduly influenced by either the surgeon who was responsible for her care or the specialist breast reconstruction nurse. Whilst we considered that to proceed with implants was not unreasonable, we were critical of the size of expander implants used at her second operation. We were also critical that the higher risk of the implant failing was not discussed with Mrs C. We found that the nurse had overfilled the implants above the manufacturer's guidelines and had not sought permission from the surgeon as she should have done. The surgeon also failed to give clear instructions about the total volume of saline to be put into the implants, and the speed at which the filling was to be done. This was particularly important given Mrs C's previous radiotherapy, which makes the breast skin more vulnerable.

Recommendations

We recommended that the board:

• contact the surgeon to share these findings about the failure to discuss and document the higher risk of implant loss when increasing Mrs C's breast size;
• apologise to Mrs C for failing to inform her of the additional risks associated with a larger implant;
• apologise to Mrs C for overfilling her implants and for not including this information in their complaint response to her; and
• ensure the findings are shared with the nurse and the surgeon and that any training needs are appropriately dealt with.