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Bristol Pathology Inquiry
May 14, 2011
January 9, 2011
Response to the Bristol Histopathology Inquiry
A member of the public commented on reading Jane Mishcon’s Inquiry Report “they think they can treat us like serfs outside the castle walls”
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.
December 9, 2010
Initial response to Bristol Histopathology Inquiry Report
The Bristol Histopathology Inquiry Report was finally released on 8th December, and can be found here:
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.
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.”
December 8, 2010
Medicine Balls, Private Eye Issue 1277
A Pathological Mess
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.
November 26, 2010
A Report on the Bristol Histopathology Inquiry
Inquiry Panel Chair, Jane Mishcon’s official report into the serious concerns about University Hospitals Bristol NHS Foundation Trust’s histopathology reporting in the specialisms of breast, lung, gynaecology, skin and paediatric pathology has not yet been published.
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.