Here is a response to the Inquiry Report for all the serfs in Bristol, North Somerset and South Gloucestershire who are expected to swallow it by those inside the castles of NHS South West, NHS Bristol, University Hospitals Bristol NHS Foundation Trust and North Bristol NHS Trust.

Public Response to the Bristol Histopathology Inquiry Report January 2011

Warning:- Swallowing everything in the official Histopathology Inquiry Report may give you serious gut disease. You might end up needing a pathologist.

http://www.uhbristol.nhs.uk/histopathology-review

Patient Advocate, Daphne Havercroft, who issued her own report in November,

Report on the Bristol Histopathology Inquiry Nov. 2010

plans a detailed response to the Inquiry Report when she has read it in more detail. Meanwhile, she has provided this initial response:

“I looked at the report to see what the Panel’s Inquiry has done to make Bristol’s Histopathology Services safer for patients, and I conclude very little. The way in which the Inquiry was conducted could possibly lead to a less safe service for Bristol because its outcome is widely regarded as a whitewash.

The Inquiry report seems to be an unnecessarily bloated 258 page document that dwells much on “playground behaviour” between NBT (North Bristol NHS Trust) and University Hospitals Bristol NHS Trust (UHBristol). It is padded out with pasted in extracts of documents and emails which seem to contribute little if anything to the question of whether the UHBristol Histopathology Service is safe and whether managers and doctors did enough to protect patients and are to be held to account for their failings.

The report contains contradictory statements, of which these are only a few examples:

39 The culture of “a Bristol disease which chips away at itself” and attitudes more suitable to the playground than to the NHS must change if there is to be a safe and effective histopathology service for the city’s patients.

It seems that the Panel telling us that the service is not currently safe because the NHS must change before it is safe.

101 Overall there is no evidence to lead us to believe that the department provides anything other than a safe service, although it still has room and need for considerable improvement.

Or is the Panel telling us that the service is safe, despite needing considerable improvement? (How can something confidently be stated to be safe if it has serious shortcomings?)

Does Jane Mishcon think the service is safe or not? Or is she hedging her bets by telling us that there is no evidence that the service is not safe, but is not able to adduce unequivocal evidence that it is safe?

60 We have absolutely no doubt that Dr Sheffield (former Medical Director, UHBristol),was trying to do his best

yet

65 Indeed, we formed the clear impression that this Inquiry was only established because of the articles in Private Eye and that, had it not been for them, the issues would have continued to be ineffectively addressed.

The Report says

75 Although every single error should be taken extremely seriously, the review by the Royal College shows that there were in fact very few cases of misdiagnosis amongst the 26 which were of the kind which no reasonably competent histopathologist should make.

The Panel has not dealt with the crucial question of whether these errors were of the kind that consultant histopathologists, not merely “reasonably competent” histopathologists, would normally make at a major teaching hospital.

76 It should also be remembered that the UHBT histopathologists report about 20,000 cases between them each year. 26 cases have been identified at NBT over almost a decade of such reporting.

This statement does not tell us how many of the 20,000 cases reported each year are UHBristol patients, whose pathology reporting is managed entirely in a department whose culture the Panel describes as “unwilling to acknowledge, let alone learn from, mistakes, and which is based on overconfidence bordering on arrogance”.

In this sort of culture, it seems highly unlikely that any uncertainties relating to UHBristol patients’ diagnoses have been and are openly acknowledged and discussed. The Royal College of Pathologists report on the 26 cases indicates that is indeed the case. It includes such comments as “the serious error is not to have sought a second opinion” and “over-confidence” in diagnosis.

Eighteen months after the Inquiry was instigated, we still have no idea whether the 26 cases are the tip of the iceberg.

The Panel says:

4.17 We were not satisfied with the way in which the 3,500 cases were selected for audit. In our opinion specimens should have been selected only from those specialties where concerns had been raised, namely respiratory, gynaecology, breast and skin…………There is no doubt that the final selection has to some extent diluted the effectiveness of assessing competency in these four specific specialist areas of concern.

and

4.18 We therefore did the one thing that we could do without spending even more money on a further review with more selective sampling: we invited Professor Peter Furness, the current President of the Royal College of Pathologists, to evaluate the evidence which was available to us and to give us his professional judgement on it.

Concerns about the methodology of the 3,500 audit were raised publicly at the start of the Inquiry. The Panel could have asserted its independence and advised UHBristol to perform a review of the specific areas of concern a year ago. This should have established very quickly whether or not the specialist histopathology services were safe, without the Inquiry incurring more costs and failing to deliver a clear answer about the safety of UHBristol’s service. The Panel did not assert its independence. The Inquiry has cost £700,000 and we still do not know whether the UHBristol respiratory, gynaecology, breast and skin histopathology services are safe.

The Panel’s Terms of Reference did not include examination of the role of the Strategic Health Authority (NHS South West), the Primary Care Trusts (particularly NHS Bristol), and the Avon, Somerset and Wiltshire Cancer Services (ASWCS) Network in responding to the allegations, despite this being a matter of public interest.

Nevertheless, Panel’s report contains this curious statement relating to August 2008 and NHS Bristol:

3.160 When several weeks later nothing had happened, the matter was discussed amongst the Network team and it was agreed that they would inform the Lead Commissioner, which was NHS Bristol.
Mr Pye (ASWCS Medical Director) therefore went to see Deborah Lee, Director of Commissioning at NHS Bristol, and discovered that this was the first that she knew about any concerns about the histopathology department at UHBT.

The Panel seems to have been extremely careless in reporting the evidence presented to it. I provided it with documentary evidence in November 2009 that proves that Ms Lee has known about the concerns since at least October 2007. I reminded Miss Mishcon of this in writing, in September 2010, yet the Inquiry Report contains this error.

The Panel’s own report indicates that Ms Lee knew about the report since February 2008. Obviously this should read February 2009, but is another example of lack of care in reporting facts.

3.207 On 5 February 2008 Deborah Lee wrote to Dr Sheffield with copies to Ms Evans, Dr Morse and Dr Rich: “Can you confirm the status of the external review of pathology services – it is some time since we saw the Terms of Reference and I’d be grateful for an update of progress/findings.

I am conscious that my criticism of the Panel’s conclusions about the safety of UHBristol’s Histopathology Services could be regarded as alarming to patients and the public. I am alarmed that after an Inquiry lasting eighteen months and costing £700,000, I still do not know whether UHBristol’s histopathology service is safe for my family and me. Nor do I know whether NBT’s services can be relied on as its entire team of breast histopathologists has resigned, the last one leaving in March 2011.

The points I have raised make uncomfortable reading. They are matters of public interest and based on facts and evidence available. I hope other families will read the Panel’s report and my report to enable them to decide for themselves whether they trust Bristol’s Histopathology Services.

An example of a good inquiry report is the Oxford Paediatric Cardiac Inquiry Report, Commissioned by the Strategic Health Authority (NHS South Central) not the Trust under investigation. Only forty eight pages long, with no unnecessary padding.

http://www.southcentral.nhs.uk/wp-content/uploads/2010/02/Review-of-paediatric-cardiac-surgery-services-at-Oxford-Radcliffe-Hospitals-NHS-Trust.pdf

By contrast, it is unfortunate that we have the Bristol Histopathology Inquiry Report – too long, contradictory, unable to positively state that Histopathology Services are safe, with supporting evidence, and containing at least two factual inaccuracies, both relating to the date that NHS Bristol’s Co-Director of Commissioning (responsible for commissioning safe, high quality health services on behalf of local people), first knew about histopathology concerns.

We seem to have an Inquiry Report whose serious shortcomings can only chip away at its credibility with the public.”

In the 18 months since the Eye reported allegations of serious errors in pathology reporting at University Hospitals Bristol (UHB) (Eye, June 8 2009), the chief executive has resigned, the head of pathology and medical director have moved on, a new paediatric pathologist was appointed and then changed her mind, and an entire team of three specialist breast pathologists at nearby North Bristol Trust (NBT) have handed in their notice. Bristol’s pathology services are clearly in a mess and yet report of the inquiry triggered by the Eye has been repeatedly delayed.

In June 2009, the Eye was sent a copy of a letter written by a senior consultant to his medical director outlining fifteen serious histopathology errors that had occurred at UHB. These were ‘examples where patients have suffered or died as a result of misdiagnosis and included missed cancers which became fatal and benign diseases treated as cancer. There were also concerns that UHB pathologists were reporting ‘in an unsafe way’ by not double-checking difficult diagnoses or releasing slides to NBT pathologists for a second opinion. The letter was dated June 2007 and in two years, there had been no independent investigation of the allegations and no reassurance that the service was safe for patients.

Other Bristol consultants raised concerns but got nowhere. One wrote about ‘a range of diagnostic errors and omissions’ in gynaecology reporting at the BRI, some of which had ‘serious implications for management’. Her concerns were met with ‘hostility and denial’ and she was sent ‘warning letters and e mails accusing me of undermining the position of the lead pathologist.’ Another consultant wrote about ‘serious misdiagnoses in breast pathology reporting’ and his desire to prevent ‘on-going disasters for patients.’ He concluded that: ‘Many believe, but are too frightened to admit in public, that this is a dangerous histopathology service.’

Richard Spicer, a former paediatric surgeon at UHB, wrote about ‘disastrous’ paediatric pathology reporting for children’s cancers and Hirschsprung’s disease (a bowel disorder). Mr Spicer raised concerns between 2001 until he retired in 2008, but was made to feel like an irritant and was ignored by successive managers. ‘I went to the chairman in desperation, because all the managers were doing nothing about the concerns raised. I filed critical reports, but it was like a black hole. Nothing was done about them – the lessons which needed to be learned were never acted upon.’

The list of serious errors being considered by the inquiry team is now 26, covering skin, lung, breast and gynaecology reporting. Three more errors have been raised since the inquiry panel was established, but there are worries that the final report will overlook child pathology and not hold to account the long list of NHS managers who knew about the allegations but failed to protect patients, most of whom haven’t a clue that the inquiry even exists.

In April, a journalist knocked on the door of relatives of Jane Hopes, a senior NHS manager in Bristol, who died of breast cancer in 2004. It is alleged that her cancer was missed at a stage when it could have been successfully treated, but her family had no knowledge of this or that an inquiry was looking into it. Iris Nicks, 72, at least knew she’d been misdiagnosed, because she was paid £12,000 in compensation last year after a breast operation to remove a cancer that didn’t exist. But she too had no knowledge of the inquiry, chaired by barrister Jane Mishcon and run by Verita. In most NHS inquiries, the evidence of those harmed is central. So why was this inquiry been conducted in secret, in London, with little attempt made to notify patients and relatives? It claims to be ‘independent’ but it’s been set up and paid for by UHB who control when and how much is published (this week, allegedly). And in the delay, changes have been rushed through that have forced the resignation of some of Bristol’s best pathologists.

NHS organisations in Bristol have said that it will be published in December 2010.

Meanwhile, this report has been produced by Daphne Havercroft, a patient advocate who has used Bristol’s histopathology services and knows the NHS well, having been involved in local service reconfigurations.

Report on the Bristol Histopathology Inquiry Nov. 2010

Daphne’s report raises the questions that, as a user of the service, she thinks the Inquiry Panel must answer. She waits to see whether Jane Mishcon has answered them in her report.

The Royal College of Pathologists describes pathology as “the hidden science that saves lives”. Patients and the public have a part to play to flush it out of hiding. A good start is to read Daphne’s report, and then the Panel’s report when it is available, to see if Daphne’s questions have been satisfactorily answered.

As Mr Spicer observes:
‘Services for children provided by the Bristol Royal Hospital for Children are uniformly excellent but Paediatric and Perinatal Pathology have been subsumed within the Department of Ault Histopathology. Managers of adult services in the BRI have controlled the destiny of the paediatric department over the last 10 years and managers within the Children’s (now Women and Children’s) Directorate have had little or no influence over the events described below even though they have ultimate responsibility for the children treated within the Children’s and St Michael’s Hospitals.

Paediatric Pathology Timeline

The Cast

GB Dr Graham Bayley, Clinical Director, Laboratory Medicine

NB Dr Nick Bishop, Medical Director

MM Dr Morgan Moorghen, Lead Clinician,Histopathology

GN Mr Graham Nix, Acting Chief Executive (afterHR)

MP Prof. Massimo Pignatelli, Head of Department of Histopathology

HR Mr Hugh Ross, Chief Executive

PR Mr Peter Richardson, General Manager, Laboratory Medicine

JS Dr Jonathan Sheffield, Medical Director (after NB)

LS Ms Lesley Salmon, General Manager , St. Michaels Hospital

The Narrative

10/7/01 Letter from Paediatric Surgeon to HR and NB warning them that actions taken by adult histopathologists and managers (notably PR) threatened to destroy the department of Paediatric Pathology.

16/7/01 Letter from Prof. of Paediatrics to HR and NB supporting above letter.

29/8/01 Letter from 8 senior clinicians in the Children’s Hospital to HR expressing concern that the lack of expert paediatric pathology was threatening the standard of care for children.

8/10/02 Letter from Lead Clinician for Children’s Surgery and Chairman of Division of Children’s Services to GN and NB expressing extreme concern that decisions taken by adult managers had resulted in the collapse of Paediatric Pathology with potential severe adverse effects on patients.

8/1/02 Letter from paediatric surgeon to MP reiterating concerns about standards of care (particularly for children with tumours and Hirschsprung disease) since adult rather than specialist paediatric pathologists were providing histopathology services for children and also concerns that no moves were being made to rebuild the department and specialist paediatric technicians were being diverted to adult histopathology.

14/11/02 Letter from Clinical Director of Obstetrics and Gynaecology to NB ,GN,LS and MM expressing concern at the loss of paediatric pathology and the severe effects of this on neonatal, fetal medicine and genetics services. He lays the blame for the loss of service at the door of UBHT managers.

1/10/03 Letter from Professor of Paediatric Oncology to various managers , including GB expressing concern that there was no management support for paediatric pathology and that a detailed report of the Paediatric and Perinatal Pathology Working Group (which he chaired) had been ignored by the Medical Director and Executive Director.

24/2/04 Letter from Prof. of Paediatric Oncology to GB, MM, MP and PR reiterating above concerns.

19/5/04 Letter from recently appointed Paediatric Pathologist complaining about lack of support from adult pathologists and managers and the difficulty of having to work within an adult department rather than having a separate dedicated paediatric department , as previously existed. This individual subsequently moved to another centre.

29/9/04 Letter from Consultant in Paediatric Intensive Care to MM highlighting the poor quality of Post Mortem services for children. This was particularly based on cases of children dying of cardiac disease and a decision was subsequently taken to send all such cases to London to a paediatric pathologist previously working in Bristol who had been forced to leave Bristol due to decisions taken by adult managers which adversely affected his working environment.

14/2/08 Letter from Prof of Paediatric Oncology to MP and JS highlighting the incompetence of adult managers in attempts to recruit paediatric pathologists. I quote “many of us have been disappointed to see how, over several years, the need for adult pathology development is seen as a competitive and (I regret to say) obstructive element in addressing paediatric pathology. In today’s NHS no one should feel the need to extinguish another person’s light just to help theirs shine brighter”.

Bristol Histopathology Timeline

Nearly seven years ago I had an unexpected encounter with cancer. Following my treatment, I decided I wanted to give something back to Bristol’s cancer services and in 2006 I joined the Breast Cancer Unit Support Trust (BUST), a small, independent charity that raises funds to support the work of the Breast Care Team at Frenchay Hospital, Bristol and has also donated equipment to the Avon Breast Screening Service.

I became involved in patient advocacy and joined Breakthrough Breast Cancer’s Campaigns and Advocacy Network and was fortunate enough to be selected by Breakthrough to attend scientific training courses and conferences with the National Breast Cancer Coalition in the United States.

I am also a consumer member of the National Cancer Research Institute Breast Clinical Studies Group, a founder member of Independent Cancer Patients’ Voice, a UK based advocacy organisation, a member of University Hospitals Bristol NHS Foundation Trust and a member of the Patients Association.

I have given evidence to the Bristol Histopathology Inquiry and was pleased that the Inquiry Panel Chair, Miss Jane Mishcon, demonstrated the Panel’s recognition of the importance of informed patient advocacy when she told me, on behalf of the Panel, that patients are very lucky to have an advocate like me.

Bristol has experienced and is still experiencing service reconfigurations to rationalise services and integrate clinical teams as part of the Bristol Health Services Plan, now called the Healthy Futures Programme, and also as part of the National Cancer Action Team’s Improving Outcomes Guidance.

No one would argue that it makes sense to rationalise services and consolidate clinical expertise. However, to deliver measurable improvements to quality of care and patient safety, careful planning is required, in full consultation with clinical and patient service users.

In my view, in Bristol, clinical reconfigurations have been implemented without proper planning of supporting pathology to ensure that histopathology is reported consistently across the city to the same agreed standards and processes. I believe this has significantly contributed to the Bristol Histopathology problem.

Although I have mentioned my membership of a number of organisations, none of them has been involved in the production of this timeline and any comments are solely mine.

However comments are largely unnecessary. Much of the source material for the timeline has come from the NHS – from correspondence, information publicly available on the internet and from Freedom of Information responses. The timeline speaks for itself. It has a number of references to “a member of the public”, obviously me. However the timeline is not about me, it is about the public accountability and probity of NHS managers (including doctors), as demonstrated by their actions when faced with very serious allegations that patients have been harmed.

Whether or not the managers were told specific clinical details of the concerns when first informed about them is irrelevant. The first rule of effective problem solving is to thoroughly investigate and define the extent and seriousness of the problem.

My reason for publishing the timeline before the Bristol Histopathology Inquiry reports is that the actions of NHS Bristol, the Avon, Somerset and Wiltshire Cancer Services Network, NHS South West and North Bristol NHS Trust are not within the official terms of reference of the UHB Histopathology Inquiry, yet, in my view, the adequacy of their responses to the allegations is key to understanding what has gone wrong in Bristol. This must be acknowledged and openly addressed if we are not to risk having yet another “Bristol” in future.

Daphne Havercroft

September 2010

13th September update to the timeline from a Freedom of Information Act (FOIA) response from he Care Quality Commission (CQC)

CQC was informed of the pathology misdiagnosis allegations by Deborah Evans, Chief Executive of NHS Bristol, on 9th June 2009, the day before Private Eye exposed them. CQC’s FOIA reply notes that after the concerns were raised with it in 2009, it received papers “which identified the concerns of management and clinicians from 2 years previously”

The reason given by Soo Sing Patel, Monitor’s Legal Adviser in this FOIA response:

Monitor FOIA response

is

“The documents comprise of information provided to Monitor by a third person, NHS Bristol. I am of the view that if NHS Bristol were to take Monitor to court for breach of a duty of confidence, on the basis of probabilities, NHS Bristol would win”.

Document 2, “Chronology provided by NHS Bristol titled UHB Pathology Issues” must be this timeline produced by Deborah Lee, NHS Bristol’s Co-Director of Commissioning (now on secondment to University Hospitals Bristol), which comes to an abrupt end 3rd March 2009, when, after apparently being given the runaround by Jonathan Sheffield, UHB’s Medical Director, and Martin Morse, North Bristol NHS Trust’s (NBT) former Medical Director, she “admits defeat and escalates to Chief Executives”.

Deborah Lee’s timeline

Deborah Lee had known of concerns about UHB’s histopathology services since at least 15th October 2007, when she was acting Chief Executive of NHS Bristol, leading an NHS presentation on reconfiguration of Breast Surgery to a Local Authority Joint Health Scrutiny Committee, and heard a clinician tell the councillors and members of the public that “some aspects of pathology services at UBHT are not up to standard” (UHB was known as UBHT before achieving Foundation Trust status on 1st June 2008).

According to a 2010 Freedom of Information Response from NHS Bristol, the PCT invited NBT to substantiate in writing and with detail the verbal allegations made at the Joint Health Scrutiny Meeting. NHS Bristol claims that NBT did not provide any evidence in support of the allegations, yet Martin Morse had received details of 15 specific cases four months earlier, in June 2007.

Despite having no evidence that patients were not being put at risk, according to Deborah Lee’s timeline, it appears that NHS Bristol did not take the misdiagnosis allegations seriously until Ms Lee was informed about them again on 22nd September 2008, eleven months after she first heard about them in public.

The Monitor FOIA response also says:

“Having consulted NHS Bristol about the release of this information they expressed the release of Document 2 would cause them harm or damage”

Ms Lee’s timeline was obligingly provided under the Freedom of Information Act to the public member of UHB by Strategic Health Authority, NHS South West.

Will Deborah Evans, Chief Executive of NHS Bristol take Sir Ian Carruthers’ SHA to court for breach of a duty of confidence?

The facts are rather more complex, as illustrated by this complaint made by a member of the public to North Bristol NHS Trust (NBT):

“Dear Complaints Department,

Contradictory Freedom of Information Responses

I write to complain about a Freedom of Information response I have received from NBT that contradicts a previous response.

Contained in my FOIA request dated 15th November 2009 was a request for this information:

Details of all circumstances (including the specialities of respiratory, breast, gynaecological and skin) whereby the patient pathway of any patients receiving any part of their treatment at NBT will require them to have histopathology reporting done by UHB. Please list all specialities where this is the case.

In respect of respiratory histopathology, on 20th January 2010, NBT answered:

Patients managed by respiratory physicians at NBT have lung biopsies performed at UHBristol and these are intially reported by UHBristol histopathologists. The histopathology is then reviewed by NBT histopathologists with the clinical team in a multi-disciplinary meeting.

In a Freedom of Information Request to NBT dated 2nd August 2010 I asked NBT to:

Explain the process for reporting NBT patients’ respiratory pathology prior to August 2008 and the process agreed from August 2008.

This was given reference number 0825-08-10 and replied to as follows on 1st September

The process for reporting respiratory histology before August 2008 was as follows:
NBT patients requiring thoracic biopsy were referred to UH Bristol. The biopsy was taken there and reported by UH Bristol pathologists. Patients with malignant diagnosis, and sometimes with a benign diagnosis were discussed at the NBT MDT and their histology was requested for review at the MDT, by NBT pathologists.
Agreement was reached in August 2008 that thoracic biopsy histology specimens on all NBT patients would be directly sent to NBT pathologists for full reporting and subsequent discussion at the NBT MDT. UH Bristol pathologists were no longer involved in reporting these specimens.

It is obvious that the process agreed between NBT and UH Bristol in August 2008 was not implemented, as is clear from the NBT response 20th January 2010 and the fact that the Sunday Telegraph 29th August 2010 reported that there had been two alleged UH Bristol respiratory misdiagnoses identified by NBT earlier this year.

Please explain why your 1st September response says that, following the August 2008 agreement, UH Bristol pathologists were no longer involved in reporting NBT respiratory specimens when that is obviously not true.

There is also the matter of what appears to be a serious issue of misleading the public. UH Bristol’s published methodology uses the following case to justify the decision to audit 3,500 cases for only one year, 2007, as one of its actions in response to allegations made by NBT staff concerning serious pathology errors made by UH Bristol in respiratory pathology reporting:

“After consideration of the number of adult cases for these years, and in discussion with the Medical Director, it was decided to take the samples from year 2007, because this was the most recent year prior to concerns being formalised by the North Bristol NHS Trust Medical Director, but was before the process changes in respiratory pathology agreed between the Trusts in August 2008″ 

As the agreement was never implemented by the Trusts, the process for respiratory pathology reporting in Bristol remains the same as it was before August 2008, with alleged errors still being discovered as recently as 2010. Therefore any argument for only auditing 2007 is destroyed.

NBT may argue that this is a matter for UH Bristol, who unilaterally commissioned the 3,500 audit. But it isn’t, it’s a matter for NBT as well because a number of your employees have raised serious concerns through proper channels over many years about potential harm to your patients.

And it is still happening because the Sunday Telegraph has reported that there have been at least three alleged misdiagnoses since the UH Bristol Inquiry commenced in 2009. Also it has now been publicly confirmed by UH Bristol that, of the 26 cases involving your patients, the Trust admitted two patients had been harmed. One of them was featured in the Sunday Telegraph.

What is NBT doing to protect its patients from possible errors made at UH Bristol? Please explain.”

Medical Solutions (now called Source Biosciences), is the company with whom UH Bristol already had a commercial relationship before commissioning it to manage the 3,500 audit. UH Bristol has confirmed that, as at the end of June 2010, Medical Solutions costs in relation to the audit were contained in a line item of £212,814 labelled “other”.

All very strange and the two Trusts seem unconcerned that with NBT staff alleging several serious errors since the Inquiry started, the question remains as to how many errors UH Bristol’s patients could be subjected to that are never identified.

MD has received a disturbing e mail Huw Morgan, a Medical Protection Society solicitor representing a pathologist who has given evidence to the University Hospitals Bristol (UHB) Pathology Inquiry: ‘It has been alleged that it was he who provided you and/or Private Eye with the information regarding such services which appeared in the 2009 issue(s) of that magazine, shortly before the Inquiry was set up. This is not the case; however he is concerned that such any such mistaken belief on the part of Panel members might be an adverse factor in their assessment of the evidence which he has given to them.’

MD has never had any contact with the pathologist, and the public money used to fund the Inquiry (£464,000 to the end of June 2010) would be better spent focusing on the specific allegations of misdiagnosis in specialist adult and paediatric pathology. Equally important is to ascertain whether appropriate action was taken to investigate the allegations. Concerns about the lack of specialist paediatric pathologists date back to 2001: ‘Over the next 2 years paediatric work was done by adult pathologists with disastrous results, particularly in the fields of childrens’ cancers and Hirschsprung disease.’ An overseas paediatric pathologist was appointed but he was reported to the GMC and removed his name form the medical register in 2004 to avoid investigation.

Allegations about the misreporting of specialist adult pathology were first raised in 2004, and NHS Bristol, the lead commissioner for UHB, has known about concerns at least since October 2007. Detailed allegations were put in writing ‘through the correct channels’ in 2007 and 2008, and the Royal College of Pathologists were aware of them long before the inquiry prompted by the Eye’s exposure in June 2009. UHB is a Foundation Trust, largely divorced from central control and supposedly accountable to its patients. It has ordered and paid for its own inquiry, agreed the terms and the statistical analysis and controls how much of the final report enters the public domain. This story is as much a failure of management as of pathology. In the 15 months since the first Eye column, UHB’s chief executive has resigned, the medical director and head of pathology have found jobs elsewhere and the report seems delayed by an ill-advised hunt for the Eye’s source.

Oxford critics beware…

In 2004, a public health specialist wrote a paper published in the British Medical Journal1 which suggested on the basis of an analysis of administrative data that Oxford had high mortality for paediatric cardiac surgery. Well before publication, two letters were sent to the Radcliffe Infirmary giving details of the results, and a reply from the Medical Director of the Trust did not dispute the figures. After publication, 16 doctors from the Oxford unit wrote to the GMC, disputing the figures and asking whether the author had ‘acted unprofessionally in bringing potentially very harmful information into the public domain in this manner.’ The author underwent a very stressful 4 month investigation, before the GMC decided that the publication of a scientific article in a major peer reviewed journal did not amount to a malicious or unfounded criticism of colleagues. Child heart surgery in Oxford is now suspended following the latest independent analysis which revealed long-standing cultural and management problems, and that ‘between 2000 and 2008, 9 deaths occurred in children undergoing less common procedures, 5.29 times the expected death rate.’ This was before a new surgeon arrived in 2009 and suffered four deaths in fifteen operations (4.8 times the expected death rate). (see Eye 1268) The authors are doubtless awaiting their letters from the GMC…..

1 BMJ 2004;329:825-9

MD