Dr Phil Hammond has kindly allowed me to post this timeline on his website to show when senior NHS managers in the South West knew about serious allegations of misdiagnosis and what they did about them.
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”