A woman had unnecessary surgery to remove her breast implants after doctors wrongly told her that one had ruptured, according to an investigation by England’s NHS Ombudsman.

The 70-year-old, who wishes to remain anonymous, had been experiencing pains in her neck and had enlarged lymph nodes for six weeks.

Clinicians at Hampshire Hospitals NHS Foundation Trust performed scans of her neck and an ultrasound of her breasts. They told the woman, who was 66 at the time, that her left implant had ruptured, and she should have both implants removed otherwise the health problems she was having were likely to worsen.

The woman, from North Hampshire, says she was not given a date for the surgery, despite contacting the Trust twice. After a month, fearing the effects of the implant’s gel leaking into her body, she says she felt she had no choice but to have the operation done privately.

It was only after the implants were removed in January 2019 that she discovered they had not ruptured and were intact.

The woman complained about what had happened to the Parliamentary and Health Service Ombudsman (PHSO), who investigates complaints about the NHS.

Radiology experts who worked with PHSO on the investigation said that the scan did not show any conclusive signs the implant had ruptured. Breast imaging standards say that if scans are equivocal, an MRI should be performed.

The Ombudsman found that if there had been an MRI, it would have been clear that the implants had not ruptured, and the woman would not have had unnecessary surgery.

The woman said, 

“I was anxious about my health, especially because of the pain I was having, along with other symptoms like pins and needles.

“I couldn’t get hold of anyone to find out when the operation would be or if I was even on a waiting list. I couldn’t stop worrying and I was in a lot of pain. I was desperate to have the implant removed so I contacted a private surgeon and they said it could be done within eight days.

“It was a massive shock when we found out the implant was intact. I had gone through all that upset and had an operation, for nothing. The NHS is meant to be the best in the world, which I still believe, but it is being let down by people not taking responsibility and poor administration.

“My husband wrote to the hospital afterwards as we wanted an apology and for them to hold their hands up. But everyone just stepped away from taking responsibility. I felt abandoned by them. You need to have accountability when you have people’s lives in your hands.”

The Ombudsman recommended that Hampshire Hospitals NHS Foundation Trust apologise to the woman and acknowledge that they should have offered an MRI scan.

They were also asked to create an action plan to show the changes it will make to ensure patients with possible breast implant rupture get the correct tests. We asked the Trust to consider paying the woman £8,771 to compensate for the unnecessary surgery and for the distress caused.

The Trust has complied with these recommendations.

Rebecca Hilsenrath, Parliamentary and Health Service Ombudsman, said, 

“When something goes wrong in the way that x-rays, MRIs or other scans are requested, carried out, or reported on, it can have significant consequences for patients and their families.

“In this case, a woman was left worried about her health and felt she had no other choice than to opt for a private operation. Finding out the surgery was unnecessary exacerbated her distress and anxiety.

“Correct interpretation of scans and following relevant guidance to carry out the right type of imaging for each situation is vital to ensure that patients receive the care they need.”

In 2021, the Ombudsman published a report about recurrent failings in the way X-rays and scans are reported on and followed up across NHS service.

The report highlighted how issues are not limited to radiologists, radiographers, or imaging services, but relate to the whole system. It made recommendations for improvement.

Read the full case summary. 

The Parliamentary Ombudsman of Malta, Judge Emeritus Joseph Zammit McKeon, hosted the Ambassador of the Kingdom of the Netherlands, H.E. Djoeke Adimi-Koekkoek on a courtesy visit to the Office of the Ombudsman.

The very cordial meeting marks another step in the constant efforts by the current Ombudsman to strengthen relations of the Office with Ambassadors and High Commissioners of Foreign Missions accredited to Malta on matters of common interest.

The Ombudsman highlighted the strong relationship between the Malta Parliamentary Ombudsman and the National Ombudsman of the Netherlands, Mr. Reiner Van Zurphen, who are both European and Global Directors of the International Ombudsman Institute (IOI).

Furthermore, the Ombudsman updated Ambassador Adimi-Koekkoek on the upcoming 13th World Conference of the International Ombudsman Institute which will be held in The Hague, the Netherlands, in May 2024.  Subjects matter for discussion during the proceedings of the Conference will include pressing social issues such as climate change, the improvement of living conditions, and the challenges facing vulnerable and marginalised groups.

Judge Zammit McKeon and H.E. Adimi-Koekkoek examined also contacts made by the Office to reach out to representatives of organisations of migrant and ethnic minority groups present in Malta, and how such contacts and their public representation may be improved and made more effective.

The Ombudsman also emphasised his commitment to see the present mandate of the Office of the Ombudsman being extended at law to become also the National Human Rights Institution (NHRI) of Malta.

In accordance with Article 22(4) of the Ombudsman Act, the Parliamentary Ombudsman, Judge Emeritus Joseph Zammit McKeon, has submitted the Final Opinion to the House of Representatives concerning a person who fell due to a pothole in San Gwann.

The Complaint

The complaint was lodged by a person who fell while descending a pavement due to a pothole situated right under the kerb in San Gwann, fracturing his left foot and sustaining other injuries. The complainant incurred expenses for mobility aids and replacement of his spectacles, which he sought to have reimbursed by the San Gwann Local Council. He argued that the Council was responsible for the pavement’s maintenance and should compensate him for his injuries and related costs.

The Investigation

The Ombudsman’s investigation involved gathering detailed information from the complainant, including medical reports, expense receipts, a police report, and statements from the complainant’s wife. The Local Council was also consulted and provided feedback on the incident. The investigation found that the Council had initially dismissed the claim, asserting that a minor road surface defect, which they did not consider a pothole, was not proven to cause the fall. The Council also noted that such defects are inevitable due to various public and private entities performing street works in the locality.

Conclusions and Recommendations

The report concluded that the San Gwann Local Council had failed to ensure the safety of the pavement and did not adequately address the complainant’s request for reimbursement. The defect in the pavement was considered significant enough to pose a hazard, which led to the complainant’s injuries.

The Ombudsman upheld the complaint, recommending that the complainant be reimbursed for all documented expenses related to the incident. The report also recommended that the Council take a more proactive approach to monitoring and repairing public roads and pavements to prevent similar incidents in the future. The report emphasised the legal obligation of Local Councils to maintain public spaces safely and efficiently.

Outcome

The San Gwann Local Council refused to implement the Ombudsman’s recommendations because it alleged that there was no clear causal link between the road defect and the complainant’s fall was not established. The Council argued that minor road defects, such as the one cited, are common and challenging to eliminate completely due to the involvement of various contractors. Additionally, the Council emphasised the need for prudent management of public funds, stating that compensation claims must be substantiated with concrete evidence directly linking the defect to the incident.

These were the same arguments submitted by the Council prior to the conclusion of the Final Opinion.

Therefore, since the recommendations were not implemented by the San Gwann Local Council, the Ombudsman, sought the direct intervention of the Prime Minister according to law. However, since the request to the Prime Minister was of no avail, the Ombudsman sent the report to the Speaker of the House, who in turn tabled the report before the House of Representatives.

In the specific case of the complainant, the Ministry of Justice exceeded the statutory deadline from Article 222 of the ZUP for issuing a decision in a renewed procedure and thereby violated the principle of legal security and the principle of good management and the principle of economy from Article 14 of the ZUP, which stipulates that the procedure must be conducted quickly, with the lowest possible costs and the lowest possible delay for clients and other participants in the procedure.

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The Human Rights Ombudsman of the Republic of Slovenia (Ombudsman) considered a complaint regarding an allegation of lengthy decision-making by the Ministry of Justice (MP) in a renewed procedure for dismissing a court interpreter.

On the basis of Articles 6 and 28 of the Human Rights Ombudsman Act (ZVarCP) in connection with Paragraph 4 of Article 9 of the same law, the Ombudsman contacted the MP with a written inquiry and, based on the response received, concluded that the MP took more than nine months to issue a decision in the renewed the procedure after the decision to allow the renewal of the procedure was issued.

Based on the above, the Ombudsman assessed that the renewed procedure in the complainant's specific case took too long and considered the complaint to be well-founded. In relation to the lengthy process of consideration of the subject matter, the MP explained that the lengthy consideration of the matter occurred due to the complexity of the subject matter, during the consideration of which it was necessary to carefully examine demanding legal issues before making a final decision in the subject matter. The MP also explained that the length of the procedure for dealing with the case in question was also influenced by the increased scope of the authority's work in the field of court experts, court appraisers, and court interpreters due to the regular verification of their expertise (1,400 persons) and the performance of administrative and other work for the Expert Council for Judicial Expertise, Judicial Valuation and Judicial Interpretation as the highest professional coordinating body in the field of judicial expertise, judicial valuation, and judicial interpretation, whereby the transfer of tasks to other civil servants was not possible due to understaffing.

The Ombudsman cannot accept the stated position of the MP. Due to systemic reasons (the authority emphasised the increased volume of the its work and the lack of staff), the procedures may take longer for a while, but they can no longer be referred to when the time required for organisational and/or personnel adaptation of the authority has passed.

The Ombudsman also noted that he did not receive a response or an explanation from the MP regarding the reason why the decision was not issued within the statutory deadline, nor was it defined. On the basis of the collected data, the Ombudsman assessed that the MP did not respond to the complainant's repeated request, nor did it, in accordance with the provisions of Article 22 of the Regulation on Administrative Operations[1], provide him with an explanation of why the decision

was not issued within the statutory deadline, which the Ombudsman considers as a violation of the principle of good governance.

In light of the above, the Ombudsman further called on the MP to respect the provisions of Article 22 of the Decree on Administrative Operations and the basic principles of the ZUP and the deadlines for decision-making prescribed therein.

In relation to the mentioned systemic reasons for the long duration of the procedure, the Ombudsman suggested that the MP consider the possibilities of additional organizational and/or personnel reinforcement.

The MP responded to the Ombudsman's proposal and explained that within the framework of the Ministry's competent services, activities are already underway in the direction of additional personnel reinforcements at the Directorate for Legislation on Organisation and for Justice Administration, with which the MP will consistently perform its administrative tasks in accordance with the principles of economy and good management, to which it is bound according to the ZUP, and in this context also ensured consistent compliance with statutory deadlines in all matters in which the MP decides on the rights, obligations, or legal benefits of the parties, which the Ombudsman welcomes.

At the same time, the MP also explained that, in this light, certain organisational measures were already adopted in 2023, with which the work process was already optimised (the organisational structure of the directorate was changed, which enabled a more appropriate distribution of work tasks and thus greater work efficiency), and systemic changes to the legislation in the field of the work of court experts, court appraisers, and court interpreters are also being prepared, which will mean both the simplification of certain procedures and the administrative relief of the Ministry, which will significantly contribute to the more efficient work of the body, which the Ombudsman also welcomes.14.5-9/2023