Woman had her breast implants unnecessarily removed after being wrongly told they had ruptured

25 April 2024

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.