This report outlines the findings of the investigation into the missed diagnosis of breast cancer on two separate occasions when a patient, referred to in this report as Ms A, presented with symptomatic breast disease in 2005 and again in 2007. It includes a review of clinical and pathology services for the care and treatment of patients with symptomatic breast disease provided by University Hospital Galway (UHG), a hospital managed by the Health Service Executive (HSE).