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”

As part of a response to a recent Freedom of Information Request from a public member of University Hospitals Bristol NHS Foundation Trust (UHB), Monitor, the NHS Foundation Trust Regulator withheld a document called Document 2, entitled “UHB Pathology Issues” – a chronology provided to them by NHS Bristol.

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?

University Hospitals Bristol NHS Foundation Trust’s (UHB/UH Bristol) audit of 3,500 cases for only 2007 was based on it being the last year “before the process changes in respiratory pathology agreed between the Trusts in August 2008”

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.