If a doctor tells you that you might have cancer and that you ought to have a biopsy, the tissue is then examined and tested by a pathologist for cancer.
It’s important that the pathologists get it right. If you have a mastectomy for breast cancer, you expect the diagnosis to have been correct so that you are not unnecessarily mutilated for a cancer you did not have.
If you are told you don’t have cancer, later you don’t expect to be told that the pathologist got it wrong and you need aggressive treatment for a disease that might have progressed to being incurable because of the delay in diagnosis.
This is the human cost (1) of wrong diagnoses and the risk can be reduced by expert double reporting.
If you believe that the pathologist would always get his/her report checked (double reported) by another pathologist to make sure that you really do or do not have cancer, you would be very wrong.
The Bristol Histopathology Inquiry Report, that examined serious concerns raised over a 10 year period about Pathology misdiagnosis in Bristol, said that some North Bristol Trust doctors were worried that the neighbouring Trust, University Hospitals Bristol, were not double reporting even when they were complex.
North Bristol’s Medical Director, Dr Chris Burton, was a member of a North Bristol team that toured Local Council meetings in March 2011 to gain support for transferring its breast care services to a different hospital site.
The team told the public, patients, GPs and Councillors that the move would enable the Trust to continue the existing standards of double reporting (100%).
Unfortunately all North Bristol’s breast pathologists resigned by the end of February 2011 and the Trust has not been able to replace them. In an understatement, Dr Burton said that the Histopathology Inquiry may have contributed to the problems in recruiting pathologists.
Much of North Bristol’s breast pathology is now reported by Source BioScience in Nottingham. According to the Trust, it is double reported.
Strange then that the double reporting protocol that was agreed by North Bristol and University Hospitals, following the Histopathology Inquiry, does not mandate double reporting for breast pathology. This despite the Inquiry Report stating the obvious – that the risk of diagnostic errors and misinterpretations leading to patient harm can be reduced if two or more pathologists review the case.
When quizzed about this Dr Burton replied (4th October) that the double reporting protocol was developed using the wording suggested by the Inquiry Panel and North Bristol took the view that its policy should follow the Inquiry recommendation not to double report in specialties other than those considered mandatory in national guidance.
However, a few months earlier, in July 2011 Dr Burton said that the procedures with Source BioScience ensure double reporting of breast pathology and although it is not mandated by the Royal College of Pathologists, North Bristol considered it good practice and intended to continue it when its breast pathology returned to Bristol.
In 2007, a North Bristol Breast Surgeon said that he and his colleague would not have University Hospitals’ breast pathologists doing their pathology because they didn’t trust them as they were not specialist pathologists and did not double report.
Now his Trust, having lost its own specialist breast pathologists, has signed up to a protocol that follows the practice of not double reporting breast pathology.
Dr Burton’s latest statement indicates that he has done a U-turn – if North Bristol’s breast pathology comes back to Bristol, he seems to be saying it won’t be double reported.
Where does this leave patients and the public who were told by North Bristol in March that the Trust would continue with double reporting?
If they need breast pathology, get it done in Nottingham?
There is a national shortage of skilled, specialist pathologists and it is acknowledged that 100% double reporting of histopathology is not possible. But if there is one place where double reporting should not be restricted to minimum, mandatory standards, it is Bristol, where the Histopathology Inquiry failed to resolve public, patient and doctors’ concerns about the commitment to safety of some pathologists. Bristol is also the place where a pathologist is currently the subject of a fitness to practice investigation by the GMC.
Interesting to consider where Dr Burton and the other doctors who agreed North Bristol’s double reporting protocol would want pathology specimens for themselves and their families reported.
(1) Examples of the human cost of misdiagnosis in Bristol
The following four University Hospitals breast misdiagnoses were considered by the Histopathology Inquiry. A fifth one arose during the course of the Inquiry and a sixth within a few days of the publication of the Inquiry Report.
1. A lymphoma in a breast lymph node was missed when it was at a stage when it might have been cured.
2. A pre-invasive cancer was missed at a curable stage. The cancer developed and the patient died.
3. In three cases patients were diagnosed with and had surgery for breast cancer. This was unnecessary because they had benign conditions. One took successful legal action for medical negligence.
4. A patient was diagnosed with a grade 1 cancer that was actually a grade 3, for which treatment is very different because grade 3 is more serious.