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Archive - Tag: Bristol Pathology Inquiry

September 16, 2010

University Hospitals Bristol Paediatric Pathology Concerns’ Timeline
Filed under: Bristol Pathology Inquiry — Tags: — Dr. Phil @ 11:49 pm

Richard Spicer, a recently retired consultant surgeon at University Hospitals Bristol NHS Foundation Trust (UHB) has compiled a timeline of the concerns raised about paediatric pathology during his time working there. The documentary evidence supporting this timeline has been submitted to the current pathology inquiry, which is due to report soon; but there are concerns that long-standing problems in paediatric pathology may be sidelined. What saddens me most is that the Bristol Heart Inquiry found that children’s services often play second fiddle to adult services, and the recommendations to prevent this happening don’t seem to have been implemented.

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”.

September 1, 2010

Dr Phil’s Private Eye Column, Issue 1270 September 1

A solicitor writes…

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


June 21, 2010

Letter to Andrew Lansley

Andrew Lansley has said that  “all service changes he NHS must be led by clinicians and patients and not driven from the top down”. This letter to him from patient advocate Daphne Havercroft should test whether he means it.

 20th June 2010

 Dear Mr Lansley,

 NHS South West – Fitness to be a Pilot Site for recommendations of the Carter Review of Pathology and concerns about transparency of the Bristol Histopathology Inquiry

Patient Advocates in the South West welcome your commitment for NHS service changes to be led by clinicians and patients.

 “all service changes must be led by clinicians and patients and not driven from the top down”

In the Bristol area, we are surprised and disappointed to find ourselves being subjected to a review of Pathology Services imposed from the top down that has been instigated by NHS South West and NHS Bristol without proper and full involvement of clinical users of the service and patients.

 NHS Bristol has produced a review initiation document that states “There is a requirement on Strategic Health Authorities (SHA’s) (sic) to ensure that all PCT’s (sic) develop plans for establishing the consolidation of services into managed pathology networks in the annual Operating Framework for the NHS in England in 2009/10.  By 2011/12 the review recommends that consolidated networks should be fully established and performing to the revised quality standards. The South West Strategic Health Authority is to be one of the two national pilot sites to deliver the Carter review recommendations and savings”

 Local patient advocates fully support a review of local Pathology Services to modernise, improve quality and safety and deliver cost efficiencies. However the top down imposition of the Carter Review recommendations looks depressingly like a variant of the same top down dogma that people in the South West have endured, without appropriate consultation, by the way in which Cancer Improving Outcomes (IOG) reconfigurations have been implemented.

 There is an urgent public debate to be had about the fitness of NHS South West to be one of the two national pilot sites to deliver the Carter review recommendations in the light of the following:

 1. Your ordering of an Inquiry into the part played by NHS South West in the dismissal of John Watkinson by the Royal Cornwall Hospitals Trust, including consideration as to whether the SHA “acted appropriately, proportionately, in keeping with its role and within its statutory responsibilities”.

 2. Public calls for the suspension of SHA Chief Executive Sir Ian Carruthers, and other implicated South West managers while the Inquiry proceeds.

3. The resignation of a highly respected and experienced patient advocate from a Cancer Group in Cornwall, alleging “bullying and intimidation” by the NHS in the South West.

 4. The poor quality of the IOG driven Bristol/Bath Gynaecological Cancer Services Review, where local patient advocate opinion is that clinicians were intimidated and bullied into silence, and similar attempts were made to do the same to patients. We believe local NHS Organisations, including NHS Bristol, tried to avoid their statutory responsibilities to consult and this was because the SHA clamped down on proper consultation, as it did for Upper GI service reconfiguration in Devon and Cornwall. Fabian Richter, Conservative Prospective Parliamentary Candidate for Bath at the 2010 Election, saw for himself the injustices that took place with the Gynaecological Review, including  NHS Bath and North East Somerset repeatedly trying to mislead patients and clinicians into believing that implementation of IOG is a legal requirement, when it clearly isn’t, being guidance. We are very grateful to Fabian for publicly articulating the concerns of local people and clinicians.

 5. The fact that NHS South West has officially known about the UH Bristol (University Hospitals Bristol NHS Foundation Trust) Histopathology misdiagnosis allegations (now the subject of a UH Bristol commissioned inquiry) since at least August 2008, and has not shown the public that it acted promptly and responsibly to protect those who raised the concerns, protect patients and ensure the allegations were properly investigated. According to a Freedom of Information Response I received from NHS Bristol on 19th June, it is alleged that the SHA knew about the serious allegations before July 2008, a year before they were reported by Private Eye Magazine.

 6. The question as to whether NHS Bristol and other local NHS organisations within the NHS in the South West, acted appropriately and responsibly when they first became aware of the Pathology concerns. In NHS Bristol’s case, this was in October 2007 and may even have been before.

 7. The extremely disappointing start to the Bristol Pathology Review where it appears that the NHS has tried to appoint a lay representative to its Project Board behind the backs of local people and without giving them any say in patient and public involvement in the Review. NHS Bristol appears to have used this extraordinary incorrect and patronising statement as a reason to exclude patient representation from the Pathology Review:

 “We must recognise that patients have little direct contact with pathology services and therefore cannot contribute their own experiences of using the services”.

 It seems that NHS Bristol will only allow patient views to be represented through local LINks Local Involvement Networks) organisations. Although I am a LINks member, I believe this is an inadequate substitute for the direct involvement of patient advocates who have actually used pathology services and have a good, basic understanding of the science of pathology and how it is central to diagnosis, treatment decisions and research.

 At the root of the Bristol Histopathology Inquiry are these and similar allegations “misdiagnosis of patients with thoracic, gynaecological and breast disease whose histopathology specimens have been reported by pathologists at the Bristol Royal Infirmary. Some of these have had fatal outcomes, and other patients have been treated for malignant disease (e.g. mastectomy and node clearance; intrapleural chemotherapy) when subsequent review showed benign disease.”

 In two of the cases the BRI admitted liability and settled with the families. Yet astonishingly, NHS Bristol appears to claim that patients have no useful contribution to make to the pathology review and will only allow tokenistic representation via LINks organisations. In our opinion, based on all the evidence of lack of consultation in the South West mentioned previously, Sir Ian Carruthers is behind this exclusion of patient advocates from direct involvement and decision making in the Pathology Review. The South West has highly experienced, well educated patient advocates and we suspect that Sir Ian fears their ability to best represent patient interests by questioning and challenging the NHS and demanding good evidence and quality assurance to support decision making.

 Following the Bristol Histopathology Inquiry, managed by Verita since December 2009, and widely  perceived as heading for a whitewash because of secrecy and lack of confidence in the way it is being conducted, Bristol’s Pathology Services urgently need to be reviewed.  It is looking increasingly unlikely that patients and the public can entrust such important work to local NHS organisations while they display obvious resistance to allowing the Pathology Review to be led by patients and clinicians, in defiance of Government expectations, and when the fitness of NHS South West, under Sir Ian Carruthers, to be a pilot region for the top down Carter Review, is highly suspect.

 South West patient advocates support the recommendations of the Carter Review in principle. However, we fear that in Sir Ian Carruthers’ South West, they will be imposed on us and clinicians without full, open and transparent consultation that meets statutory requirements. We believe that     this may lead to less safe and lower quality Pathology services in the South West.

 We ask you to consider and advise whether, with its track record of suppressing patient and clinician leadership of NHS service change, and with a Chief Executive widely regarded as fostering a bullying and intimidatory culture, NHS South West is an appropriate and safe site to be a pilot for the Carter Review recommendations.

 We would also appreciate knowing the coalition Government’s position on the importance and validity of the Carter Review recommendations in respect of local pathology service reconfigurations. As it is a top down recommendation it is unclear to the public whether it can be easily reconciled with the requirement for all service changes to be led by clinicians and patients, not imposed from above. 

 As you have asked Verita to conduct the Inquiry into the circumstances surrounding the John Watkinson Industrial Tribunal, we suggest that you may also wish to inquire into public concerns I mentioned earlier about the Bristol Histopathology Inquiry, which is managed by Verita. One of the reasons for the concerns (there are others) is that the Terms of Reference of the Inquiry do not include investigation into role of NHS South West, NHS Bristol (and other local Primary Care Trusts) and the Avon, Somerset and Wiltshire Cancer Services (ASWCS) Network in respect of their response to the allegations. A lesson learned from the Bristol Royal Infirmary Heart Inquiry is that it is important to know from the organisations and individuals responsible for patient safety and quality of care the answer to these questions:-  what did you know? when did you know about it? what did you do about it? It appears that NHS South West, NHS Bristol and ASWCS will be protected from being accountable to the public to answer these questions. This is not right.

 We also request your intervention to protect our rights and those of clinical users of pathology services to be fully involved and consulted by insisting that NHS South West and the organisations that report to it ensure that any Bristol area Pathology Review is led by local clinicians and local patients, without intimidation and bullying by NHS South West and other local NHS organisations.

  Yours sincerely,

 Mrs Daphne Havercroft

 Consumer Member, National Cancer Research Institute, Breast Clinical Studies Group

Trustee, Independent Cancer Patients’ Voice

Member, South Gloucestershire LINks

Member, Breakthrough Breast Cancer Campaigns and Advocacy Network

Member, Bristol & Weston Breast Care Services Review Project Board

Independent Patient Adviser, Bristol & Bath Head and Neck Cancer Services Review.

Graduate, Project Lead & Project Lead Clinical Trials

copied to:

Steve Webb, MP for Thornbury and Yate

Jack Lopresti, MP for Filton and Bradley Stoke

Fabian Richter

Paul Burstow, MP, Care Services Minister

June 16, 2010

An Open Letter to the Bristol Histopathology Inquiry
Filed under: Bristol Pathology Inquiry — Tags: , — Dr. Phil @ 11:50 am

Daphne Havercroft, an experienced Patient Advocate,  has written an open letter to the inquiry that encapsulates all the concerns of those who fear we’re heading for a whitewash.  

Dear Miss Mishcon,

Bristol Histopathology Inquiry – Open Letter

I write concerning the 26 alleged cases of misdiagnosis that UHB (University Hospitals Bristol NHS Foundation Trust) arranged to be externally reviewed. They cover four specialist areas:- respiratory, gynaecological, breast and skin.

 From UHB and NBT (North Bristol NHS Trust) Freedom of Information Act responses, I understand the following:

  1. NBT identified the 26 cases following histopathology case review, with little involvement of the clinicians who raised the allegations.
  2.  The patients affected (if still alive) and/or their families, appear not to have been informed that their case is part of the Inquiry and invited to give evidence to the Panel, as demonstrated by the Jane Hopes case reported in the Sunday Telegraph 11th April 2010.
  3. UHB’s laboratory staff extracted slides to send to Medical Solutions, a company with a financial relationship to UHB, for review by pathologists whose names are secret.
  4. Pathologists who raised the concerns were not asked to verify that the slides, reports, existing external opinions and any other material that UHB sent for review are the ones that are the subject of the allegations.
  5. There appear to be no formal plans to communicate the findings of the external review to pathologists who raised the concerns and those whose work is the subject of the concerns, to allow them to comment on the findings.
  6.  UHB’s Acting Chief Executive has confirmed that, of the 26 cases, there were “2 cases of misdiagnosis leading to patient harm where the Trust admitted liability and a settlement was reached”. He does not say whether the settlement included a “gagging” clause that prevents the families from meeting the Panel.
  7. The 26 cases may be the tip of the iceberg. UHB’s apparent reluctance to investigate this  indicates that fear of litigation overrides exposure of the facts. The 26 cases are a small sample of the caseload in the four areas of concern. If an audit of just these subspecialities was performed, covering all years for which allegations have been raised, the error rate may be higher than the 1-2% claimed as a “normal” error rate by the Trust.
  8. The 3,500 random audit of cases or specimens (it has never been made clear which),   commissioned by UHB for 2007, includes large specialities for which no concerns have been expressed. As well as causing anxiety to pathologists in those specialities, the audit is likely to mask the extent of any serious errors made in the specialities of concern.

The public wants to know whether or not serious, avoidable misdiagnoses have occurred, which have harmed or could harm patients; not whether UHB’s Histopathology Department had an overall error rate of less than 2% for 2007.

 The public wants the truth about the extent to which the concerns were dealt with in an open, honest and constructive manner. Or have no lessons been learned from the Bristol Heart Inquiry?

All histopathologists make some mistakes. However UHB has admitted that two of the 26 cases involved patient harm. We want to know whether other avoidable mistakes have been made that harmed patients, or had the potential to do so if not spotted and corrected by colleagues in other Trusts.

We want to understand whether histopathologists working in the areas of concern have been performing to standards that are expected of their position as specialist pathologists in a tertiary referral centre and whether all have been participating in EQA (External Quality Assurance) schemes for the subspecialities of breast, respiratory, gynaecological pathology and dermatopathology.

The secretive conduct of the review of 26 cases does not inspire confidence that these questions will be answered.

Public confidence will be further undermined if the Panel is not seen to acknowledge this and demonstrate its independence now by insisting on full transparency in the investigation of the 26 cases.

Adverse public and press reaction is inevitable when the organisation against whose staff the allegations have been made, selects the evidence for investigation without any input from those who made the allegations, pays for its existing contractor to handle the evidence and engages and pays for a Panel to provide assurance that all is well.

 I am confident that the Panel has the opportunity to exert its independence by ensuring full transparency in uncovering and publicly reporting the facts about the 26 cases as an urgent prerequisite for developing the consistent high quality, safe pathology services that Bristol desperately needs.

 The issue is whether the Panel has the will to seize this opportunity.

 I hope that this letter is helpful to you and your colleagues on the Panel in clarifying the expectations of patients and members of the public.

 Daphne Havercroft

 Patient Advocate

 14th June 2010

May 28, 2010

The Bristol Pathology Inquiry, as seen by Private Eye
Filed under: Bristol Pathology Inquiry — Tags: — Dr. Phil @ 4:43 pm

The Bristol Pathology Inquiry was triggered by my Private Eye column in June 2009 detailing allegations of significant errors in histopathology reporting at the Bristol Royal Infirmary, part of University Hospitals Bristol (UHB). Initially, allegations of error were made by four senior sources working at nearby North Bristol Trust (NBT) and covered the areas of respiratory, gynaecology, breast and skin pathology. A further source from within UHB then made serious allegations about long-standing errors in paediatric pathology, a shortage of paediatric pathologists and specific allegations about a named paediatric pathologist who was eventually reported to the General Medical Council but removed his name from the Medical Register and so was not investigated.

Incompetence can be extremely hard to define in a doctor, particularly a pathologist, given the complexity of some cases and the subtleties in interpretation of tissue samples. It was, and remains, unclear as to whether these alleged errors are as a result of general incompetence, or whether otherwise competent pathologists were working at the margins of their competence in dealing with particularly hard to interpret samples. In a grown-up safety culture, pathologists in the two hospitals would readily share samples and combine expertise and resources to give patients the best chance of the right diagnosis and the most appropriate treatment. The fact that this doesn’t appear to have happened in Bristol and that these allegations have been grumbling on for years without resolution (and without patients knowing about them) is a damning indictment of both of the inept management and secretive medical culture, and suggests that the lessons of the heart scandal have not been widely applied.

The heart and pathology inquiries differ in so far as the heart inquiry was in public, was easy to find out about and many patients and relatives were able to give evidence to it, whereas the pathology inquiry is being held in secret, in London rather than Bristol, and very few patients or even doctors are aware that it is happening. The Inquiry is due to report later this year. If you want to find out more or give evidence, contact:

David Jones
Inquiry Manager


53 Frith Street

London W1D 4SN
Tel: 020 7494 5670

In the meantime, here’s Private Eye’s telling of the story so far…..

Private Eye: June 10, 2009

Pathological Sickness


On June 1, 2007 a letter was sent to Dr Martin Morse, Medical Director of North Bristol Trust (NBT), detailing eleven alleged serious diagnostic errors made by histopathologists at the Bristol Royal Infirmary, resulting in significant patient harm. These cases  came to light when slides and samples were subsequently reviewed at NBT.

According to the allegations, one woman (now deceased) was told her breast biopsy was benign but later presented with metastatic cancer, and patients with malignant lymphoma, melanoma (twice) and vulval carcinoma were also initially told they did not have cancer. Conversely two other patients allegedly had treatment for cancer when review of their biopsies found no evidence of it.

Documented errors appeared most likely in patients with rare lung disease. Again, patients have allegedly been told they have cancer when they don’t, and vice versa. Another was allegedly told he had tuberculosis when subsequent review found that he didn’t.

Interpreting tissue slides is stressful and complex, and some mistakes inevitably happen. The Royal College of Pathologists (RCPath) clearly states that when discrepancies in reporting occur, prompt independent review is required but some of these errors date back to 2000, and when the college was invited to do such a review, it apparently declined as it did not want to get involved in an ‘internal matter.’

Bristol is blessed with some fine pathologists, including respiratory specialists based at NBT, and if they worked in teams, accepted the same quality control and shared difficult diagnoses, then doubtless some harm to patients could have been prevented or reduced.

Alas, the long-standing rivalry between Bristol hospitals has prevented this from happening. Until July 2008, NBT pathologists claim they were unable to access the slides for their patients who were treated at the BRI, though this has now been resolved. However, slides from other patients who might benefit from the specialist service at NBT are still not being shared. Dr Morse has raised concerns with the Medical Director of University Hospitals Bristol (UHB), Dr Jonathan Sheffield but – two years after the whistle was blown – an independent external review has not happened. Four additional cases of apparent lung misdiagnosis have now been documented, but Dr Sheffield has stated that there is ‘no evidence to confirm a significant error rate’  in the service.

As well as the RCPath, these concerns have been brought to the attention of the chief executives of both trusts, the medical director of the strategic health authority, the medical director of the Avon Somerset and Wiltshire Cancer Services and the National Clinical Assessment Authority, thus far without satisfactory investigation or resolution.

It seems extraordinary, given what happened previously in Bristol, that UHB staff would not accept they might have a problem in their pathology department and act quickly to get an outside assessment. An urgent external review and the assimilation of pathology services across Bristol into a network that encourages scrutiny and shared expertise is now vital for patient safety. Dr Sheffield and the RCPath have been sent a detailed summary of the alleged misdiagnoses and MD has asked Barbara Young at the Care Quality Commission to investigate.

Private Eye: June 20, 2009

Has Bristol learned from Bristol? 


How much has the safety culture at University Hospitals Bristol (UHB) changed since the public inquiry into cardiac surgery? On the plus side, when the Eye broke the heart scandal in 1992, it took seven years to announce an external inquiry. When allegations of serious histopathology errors were published last month (Eye 1238), it took seven days.  There’s even a web page dedicated to the histopathology review.

But  there’s still plenty of ‘old’ Bristol. Too much power concentrated in too few hands, very serious allegations not shared with the trust board, arrogance and bullying, a shortage of specialist staff, an ineffectual royal college and a brave consultant who raised concerns but felt compelled to leave Bristol when they were not taken seriously. And once again, many doctors, managers and establishment figures have been well aware of the problems for some years, but virtually no patients.

The UHB website says the review was ordered after ‘15 potential cases of histopathology misdiagnosis’ were published in ‘the satirical magazine, Private Eye.’ But the trust knows that there are far more than 15 alleged errors dating back from 2000. These are a sample of the errors collated by a single consultant where significant harm to patients had occurred. There are other examples where harm was fortuitously averted. Other consultants have also raised concerns specifically in four areas (respiratory, breast, skin and gynaecology), some as far back as 2004.

Other allegations that have been explicitly made to the UHB medical director Dr Jonathan Sheffield or the chief executive Dr Graham Rich since 2007 include:

UHB pathologists not routinely sending difficult slides for an outside opinion

Diagnostic errors and omissions in gynaecology reporting picked up by a specialist pathologist over a 2 year period with ‘serious implications for patient safety.’ The more serious errors were confirmed by an external expert.

Attitudes of hostility and denial when the above concerns were raised, a smearing of the specialist and a consequent abandonment of the specialist scrutiny of gynaecology reporting

Formal and informal complaints against a lead UHB pathologist.

Coroners reports performed to a substandard level by UHB  pathologists but no action taken.

Deficiencies in UHB pathology audit

Dr Sheffield, himself a histopathologist, has frequently met and exchanged correspondence, with those raising concerns but to no satisfactory resolution In July 2008, the minutes  of the Medical Advisory Committee at North Bristol Trust (NBT), state that there ‘continued to be serious cases of respiratory misdiagnosis by UHB histopathologists of specimens from NBT patients, despite there having been assurances by UHB that the problems had been overcome’ and ‘UHB continued to refuse to allow slides to be looked at by NBT histopathologists.’ Dr Morse, then medical director, said that unless an external review was arranged, he would report the matter to the Healthcare Commission. In August 2008, Graham Rich gave a written assurance that an external review had been requested. It never happened. The Royal College of Pathologists was contacted but claim they never received the formal agreement of both trusts to do the review. And without an invitation, the royal college is powerless to intervene even if serious misdiagnosis is occurring.

Forced into action by the Eye, UHB has organised  its own external review using a private company called Medical Solutions, which already does the trust’s breast cancer receptor testing, and so has a financial stake in one of the four areas of concern. Hardly independent. 3,500 slides across the entire pathology service are going to be chosen at random for one year (2007) to see if there is a significant error rate. If UHB had proper prospective audit,  it would already know what it’s error rate is for subspecialties and pathologists. The random selection will not include any errors prior to 2007 and, according to one statistician, ‘is fraught with methodological problems and  extremely unlikely to get to the heart of the problem.’

Specialist pathology is not simply making a diagnosis of, say,  benign or malignant but recognising other features of the tissue that should guide very complex treatment in discussion with the entire team. There is a national shortage of specialist pathologists, and Bristol can only provide a safe service by merging the expertise of its two trusts. As one senior consultant at NHS Bristol put it: ‘We’ve been trying to do this ever since I arrived in Bristol 25 years ago.’ The external review is looking for the wrong problem in the wrong place.  It’s changing the culture and service afterwards that matters. Time to grow up and get on with it.

Private Eye: September 11, 2009

The histopathology review at University Hospitals Bristol prompted by the Eye’s exposure of allegations of serious errors in reporting of skin, breast, lung and gynaecology specimens between 2000 and 2008 (Eyes passim) may have to cast its net still wider. A senior specialist with many years experience working at UHB has now demanded that paediatric pathology be investigated too.

The paediatric pathology department was recognised as one of the best in the world prior to the Bristol heart inquiry in 2001, with three specialists including a professor and a senior lecturer. The samples they kept were instrumental in proving that the standard of complex paediatric heart surgery prior to 1995 had been so poor. When it emerged that most of the samples had been kept without parental consent, the pathologists were hung out to dry in the press and, unsupported by management, they left.

According to the allegations: ‘Over the next 2 years paediatric work was done by adult pathologists… from a highly dysfunctional department, some of whose competence in their own fields was in doubt. The results were disastrous, particularly in the fields of children’s cancers and Hirschsprung’s disease. In 2002-2003, the Trust appointed a non-UK trained paediatric pathologist, Dr S,  who had not been short-listed for posts elsewhere. He should never have been appointed and within a few months it was apparent that he was incompetent. Serious errors in children with cancer and Hirschsprung’s disease continued (one of the latter died as a direct result of this). His post-mortems were of a very poor standard. This caused particular problems in children dying of heart disease. After clinical staff reported numerous incidents to managers they were eventually forced to take action and he left to work in Europe.’

‘In 2004, two new paediatric pathologists (PP) were appointed but one found the environment so hostile that she left in 2005. Since 2005 a single-handed PP has soldiered on valiantly despite hostility from adult pathologists and little help from managers. The standards are very high when she is there but there are still major problems when she’s away. She does all the biopsy work but not post mortems. £450,000 comes to the Trust for regional perinatal work and the adult pathologists have tried to keep this for their own use. They have also used devious tactics to try to block appointments to the 2 vacant PP posts. It is hoped that one post will shortly be filled but meanwhile there are serious deficiencies affecting oncology, cardiac, genetic and surgical services.’

In response, UHB has referred all these new allegations to the pathology review team, to be chaired by Jane Mischon. In addition, ‘the incident alleged in the letter was fully investigated at the time.  As a result, the Trust reported an individual to the General Medical Council, whose name was removed from the medical register at the end of 2004.’ Meanwhile, in the draft minutes of a June 12 2009 meeting, UHB gynaecologist John Murdoch refers to the Eye’s reporting of Trust’s pathology problems as ‘sensationalist’ and referring to ‘a few lung cancer cases’.  In fact, many of the allegations are in his own area and the Trust has confirmed that ‘Mr Murdoch was aware of the serious allegations about gynaecology reporting in June 2008.’ Odd that he should not minute them a year later.

Private Eye  September 25, 2009


The GMC  has issued a puzzling statement about Dr S, a paediatric pathologist employed by United Hospitals Bristol (UHB).  According to the GMC: ‘We received information from UHB in 2004 regarding Dr S. It became clear that conducting our normal investigations was going to take longer than was in the public interest. We therefore decided to remove the doctor from the register with his agreement. The doctor was removed from the register in December 2004 and has not been registered with the GMC since that date. This means that he has not been able to practise as a doctor in the UK since 2004.” 

MD has asked the GMC to clarify how it can be in the public interest not to investigate serious concerns about patient safety, but without reply. One argument used locally to silence dissenters is ‘the last thing Bristol needs is another scandal.’ In fact, the last thing Bristol needs is another cover up. Jane Mishcon, chair of the UHB pathology review,  has a lot of digging to do. Meanwhile Dr S is now a Professor in Canada, citing ‘Clinical Reader at the Bristol University’ as one of his achievements.

Private Eye: January 20, 2010


Bristol Update


‘Failure to reconfigure child heart surgery will be a stain on the soul of the specialty and will compromise the treatment of the most vulnerable members of the next generation.’ So says NHS Medical Director and cardiac surgeon Sir Bruce Keogh, just 18 years after the Bristol heart scandal was exposed in Private Eye. The Public Inquiry a decade ago found that as many as 35 babies had died unnecessarily, and a review in 2003 recommended the concentration of scarce expertise and equipment in fewer centres. Alas, Labour ignored it for fear of the political ramifications.  Keogh admits there has ‘frankly been little progress’ since the inquiry and he can’t at present guarantee that ‘another Bristol’ won’t happen. 

The job of fixing it has now been handed to the National Specialised Commissioning Group (NSCG), which since 2007 has been responsible for making sure the treatment for all rare and complex conditions is ‘safe and sustainable.’ As Keogh puts it: ‘The NSCG has to flex its muscles. Politicians  have to accept their recommendations and clinicians have to put aside personal conflict and institutional self interest.’ And patients and parents have to accept they may have to travel further to get the best treatment. We shall see.

The battle to safely reconfigure specialist services is also at the heart of the current Bristol pathology inquiry, which MD is due to give evidence to next month. The Royal College of Pathologists (RCPath) describes pathology as ‘the hidden science at the heart of modern medicine’ but it’s high time it was flushed out into the open. As medicine becomes increasingly technical and individualised, there is an urgent demand for specialist pathologists with the experience to spot the complex nuances in tissue samples and advise on treatment. Alas, specialist pathologists are in short supply and the temptation, to save money and hold onto business, is to let those with insufficient expertise report on complex slides.

This is the allegation made against pathologists at University Hospitals Bristol, with evidence submitted of serious reporting errors for complex gynaecology, respiratory, dermatology, breast and paediatric tissue samples. There is also evidence that, as with the heart scandal, a lot of senior NHS managers, consultants and the royal college have known concerns about UHB’s pathology department for some time. So there are powerful vested interests in not having another scandal.

UHB ordered the external inquiry, chaired by Jane Mishcon, but only after the Eye went public with the allegations. The Trust was initially overseeing the inquiry, but this clearly lacked independence and it has now transferred to London under the management of Verita. However, the inquiry panel has no control over the analysis of samples. The alleged errors reported to MD have occurred between 2000 and 2009, and all in specialist areas. Whereas the inquiry is looking at a random sample of 3,500 adult slides taken across a single year and including all the ‘bread and butter’ reporting, so complex mistakes can be buried and the overall error rate will look small. This is precisely the tactic used in defence of the heart surgeons. The inquiry needs to focus its attention on specialist areas and specific cases.

Against this background, local cancer services are in the process of being reconfigured to make them ‘safe and sustainable’. All are highly dependent on co-operation between hospitals and developing specialist pathology services but whether Bristol’s clinicians and managers can work together and share expertise remains to be seen. Oh, and UHBs chief executive Graham Rich has just resigned.

Private Eye: January 26, 2010

Very human errors  

Last year, MD met an Australian surgeon who tells his junior staff: ‘Your job is to stop me killing anyone.’ Nurses, receptionists, patients and relatives are all encouraged to speak up if they think something isn’t right, and it’s looked into promptly without knee-jerk blame. As a result, his cock-ups and complaints are commendably sparse and he has no shortage of applicants for his training posts.

The NHS has been trying to develop a grown-up safety culture for over a decade, but there is still a huge reluctance for staff to comment on each other’s work. A senior nurse who helped developed the national guidelines for the safe and sterile insertion of central venous lines recently observed a junior doctor putting a central line with a clearly dirty technique. The drapes weren’t in place and there was a danger he would introduce infection directly into the patient’s blood stream. But because it wasn’t her patient and she didn’t know the doctor, she didn’t feel in a position to comment.

The reticence of some NHS staff to offer constructive criticism and the unwillingness of others to accept it is at the heart of many clinical errors. When serious errors are analysed in detail, staff have often spotted something wrong but not said anything, or tried to raise concerns and not been taken seriously. In the infamous ‘wrong kidney’ disaster, both the medical and nursing students tried to point out the surgeon was operating on the wrong side. And in the death of Elaine Bromiley (Eye 8.5.08 ), nurses recognised that she needed an emergency tracheotomy after a failed anaesthetic,  and even brought the kit into the operating theatre, but didn’t feel able to interrupt the consultants.

Elaine’s husband Martin, a pilot, founded the Clinical Human Factors Group (CHFG) to help the NHS learn that guidelines and checklists are pointless without behavioural and cultural change. Under pressure, even the most senior doctor can panic, develop tunnel vision and go badly off piste, and without a team ethos that allows someone more junior to point this out, a disaster inevitably happens. The CHFG has now joined forces with the Patient Safety First campaign for a series of webcasts on the importance of addressing human factors in preventing medical error. One relatively simple idea is to encourage anyone performing a procedure to say: ‘If you think I’m going to make a mistake, please tell me.’ This also applies to patients and relatives. A change of pill colour or site of infusion is always worth querying. And given that 1 in 10 patients are harmed by their treatment, even a modest reduction in medical error could pay huge dividends.

Picking up errors after the event is also important. Pathologists are particularly vulnerable because tissue patterns are complex and subtle, and samples reported under stress are then stored for others to analyse at leisure. Specialists are also in short supply and this makes it imperative that pathologists work in teams and networks across regions, double checking difficult samples and seeking expert opinions. In Bristol, where pathologists in one hospital have tried to raise concerns about errors at another, the culture appears to be stuck in ‘how dare you question my reporting?’, rather than ‘let’s work together to make sure this patient gets the correct diagnosis and best treatment.’ Whether the current inquiry sorts it remains to be seen, but the pathology departments of both hospitals could do worse than sitting down together for the Truth and reconciliation following serious harm webcast (Thu 4 Feb, 10.30-11.30)1

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