A Tale of Two Deborahs

Bristol Histopathology

Editor’s Note:  This is the history of exposing what happened at Bristol for gynaecological patients who were misdiagnosed.  We provide all evidence and allow readers to judge for themselves.  We welcome comments from the primary care trust on when they knew of the gynaecological concerns.

BRISTOL PRIMARY CARE “TRUST”?

10th June 2009
Private Eye Magazine broke the story of 15 histopathology misdiagnoses detailed in a 1st June 2007 letter from an North Bristol Trust Doctor to the then Medical Director, Martin Morse.

Shortly afterwards, University Hospitals Bristol NHS Foundation Trust announced an inquiry into the 15 cases. Gynaecological allegations were not included, despite the University Hospitals CEO, Dr Graham Rich, having received a letter a year earlier in June 2008 from an North Bristol doctor, alerting him to diagnostic errors in histopathology, including Gynaecological concerns. This letter was copied to Dr John Savage, Chair of the University Trust and Miss Sonia Mills, then Chief Executive of North Bristol.

19th June 2009
BBC Points West broadcast the pathology concerns, mentioning that there were gynaecological errors identified over a two year period.

http://news.bbc.co.uk/1/hi/england/bristol/8109011.stm

22nd June 2009

I sent a letter to Dr Jonathan Sheffield, then Medical Director of University Hospital, asking him to tell me “the number of gynaecological cases that were allegedly misdiagnosed and confirm that they will all be included in the scope of the external review.”

26th June 2009
Dr Sheffield did not reply. However I received a letter from Ms Deborah Evans, Chief Executive of NHS Bristol (formerly known as Bristol Primary Care Trust) dated 26th June.

Included in Ms Evans’ letter, page 2, is this statement:
In your letter of 22nd June 2009 to Jonathan Sheffield, you talk about gynaecological cases which were misdiagnosed and you ask for a review of these individual cases. I have been unable to establish what you refer to in this instance

and

I have asked the Medical Director at North Bristol Trust to establish whether there are any concerns about individual gynaecological histopathology cases which we are not so far aware of”.

On 29th June 2009, I informed Ms Evans by email that I was referring to the “allegations of gynaecological misdiagnoses” that were mentioned in the BBC Points West Report ten days earlier.  But, Ms Evans’ letter dated 26th June 2009 asking about gynaecological concerns is extraordinary and very disturbing for these reasons:

1. On 27th August 2010, NHS Bristol Board Chairman, Mr Richard Weatherhead, confirmed to me in writing that “on 23rd September 2008 [ten months before Mr Evans' 26th June 2009 letter]………..Deborah Lee [former NHS Bristol Director of Commissioning] orally advised Deborah Evans that concerns had been raised including concerns around breast lung and gynaecological….”  Which would mean, on the face of it, that both “Deborahs” knew about the gynaecological concerns in September 2008.  Shhurely?

2. NHS Bristol then commissioned a review conducted by a Panel comprising two of its non-  executive directors and the Chair of NHS Somerset to examine the actions of NHS Bristol in the events leading to the Histopathology Inquiry (Board Meeting agenda items 9.3 and 9.3a)

http://www.bristol.nhs.uk/about-us/our-board/board-meetings-2011/april-28.aspx

But NHS Bristol’s Review Panel claimed that “a specific allegation had been made by a member of the public that Ms Evans was aware of specific gynaecological cases and did not disclose this knowledge. The Review Panel did not find any evidence that supported this allegation.”  But was this allegation really from a member of the public?

No, it seems to have come from their own Chairman’s letter, from Mr Richard Weatherhead.  Nevertheless, the Review Panel, went on to state that “Ms Evans demonstrated that repeated requests to NBT were made by herself and Ms Lee for information about specific cases. Despite these requests there is no evidence that this information was made available until Ms Evans personally visited NBT on the 24 June 2009.”  And, “It is the Review Panel’s view that Ms Evans acted with propriety and appropriate energy and with the support of her Board throughout.

The Panel did not find any evidence – because the allegation was never made (see my letter 22nd June 2009 to Dr Jonathan Sheffield). On 27th June 2011, I received a letter from NHS Bristol Board Chair Mr Richard Weatherhead, stating that “I apologise if I have inadvertently misrepresented your views……I realise now…..that you are in fact stating that Ms Evans had an understanding that there were concerns that included gynaecological cases”.

4. Well, yes Richard – that’s my understanding from what you told me on 27th August 2010. I had no idea when Ms Evans first knew about specific cases until I saw the NHS Bristol Review Panel’s Report in May 2011. For NHS Bristol and its Review Panel to accuse a member of the public of making allegations when evidence confirms they never made them seems remarkably like the sort of bullying that NHS staff are subjected to.

The Panel’s conclusion about Ms Evans’ propriety and energy is interesting when one considers that her Board Chair has confirmed that she was aware that there were breast and gynaecological concerns as well as lung on 23rd September 2008, yet the Review Panel asserts that Ms Evans was unable to prise the specific case details from North Bristol until ten months later.

5. The Review Panel notes that “Within the system of regulation Primary Care Trusts are required to hold NHS trusts to account for their delivery of commissioned services. This accountability extends to the clinical quality of services“. Yet the Panel expresses no concern and no surprise that NHS Bristol clearly failed to hold University Hospital and North Bristol to account for the quality of histopathology services about which clinicians had expressed concern in a public meeting on 15th October 2007 in the presence of Deborah Lee, then NHS Bristol Director of Commissioning. (Review Report, Page 4, item 7 Key Events)

The two most worrying aspects of this whole business are…

Firstly,

The NHS Bristol Review Panel states this in Appendix 2, Chronology of Events:

24 June 2009 Ms Evans visited North Bristol Trust and requested to see evidence relating to the allegations of misdiagnosis of breast and gynaecology cases. The Trust provided specific details.”

Yet two days after receiving specific case details from North Bristol, Ms Evans wrote to me claiming to have no knowledge of Gynaecological concerns and specific cases.

I question whether the gynaecological cases would have been included in the Histopathology Inquiry if I had not asked for assurance that they would be.

Secondly,

According to the Review Panel, Ms Deborah Lee did not inform her CEO, Ms Evans of misdiagnosis concerns, including breast and gynaecology until September 2008, yet Ms Lee attended a Health Scrutiny Meeting at Bristol Council House on 15th October 2007 when she heard a North Bristol doctor, specialising in breast pathology, say publicly, in the presence of his Medical Director, Martin Morse, that some aspects of University Hospital’s pathology are not up to standard.

According to University Hospital’s Histopathology Inquiry Report, published in December 2010, the Medical Director of the local cancer network went to see Ms Lee sometime during August/September 2008 and “discovered that this was the first that she knew about any concerns about the histopathology department (at University Hospital)“.

However, NHS Bristols Review Panel’s Report confirms what public witnesses at the 15th October 2007 Health Scrutiny Meeting know – that Ms Lee knew about concerns ten months before the date the University Hospital Inquiry Report claims she knew about them.

The NHS Bristol Review Panel reports that on 16th October 2007, Ms Lee discussed the matter with Martin Morse asking him to provide evidence to support the concerns, sent a confirmatory email, yet received no response. This is strange because Dr Morse had received details of 15 cases four months earlier, in the June 2007 letter mentioned by Dr Phil Hammond in Private Eye, two years later in June 2009.

NHS Bristol’s Review Report confirms that nothing further happened until 22 July 2008  when the Safer Patient Initiative Lead at North Bristol raised concerns about University Hospital’s pathology quality with the cancer network.

6. The NHS Bristol Review concluded that:

The Review Panel did not find any evidence to suggest that the Chief Executive or the other directors involved acted in a way that conflicted with the NHS Code of Conduct or acted inappropriately during this process.

7. The Code of Conduct for NHS Managers includes the following:

“As an NHS manager, I will observe the following principles:
make the care and safety of patients my first concern and act to protect them from risk;

respect the public, patients, relatives, carers, NHS staff and partners in other agencies;

I will be honest and will act with integrity and probity at all times.”

8. According to the Department of Health, 18th May 2011:

If chief executives or directors are to
 be investigated, (for alleged breaches of the     Code of Conduct for NHS Managers) the employing authority should use individuals who are
 employed elsewhere to conduct the investigation. The NHS Confederation,
the Institute of Healthcare Management and the Healthcare Financial
Management Association are among the organisations that maintain lists
of people who are willing to undertake such a role.

It is not clear why NHS Bristol thought it acceptable to ignore these guidelines when it decided to carry out a review of the actions of its Senior Executives, including the Chief Executive.

What was it thinking to expect the public to accept that investigation by two of its own non-executive directors and the Chair of a nearby Primary Care Trust was sufficiently independent and unbiased?

Why did it not occur to NHS Bristol that it is not only the appropriateness of the actions of its executive board members that are of public interest in this affair, but the actions of the non-executives too?

What might be the effect on Bristol’s Gynaecological Cancer patients of UHBT’s Chief Executive and Board Chair not acting on the letter they received in June 2008 and Ms Evans taking ten months from knowing about gynaecological concerns in September 2008 to obtaining specific details in June 2009?

We do not know because University Hospitals’ Inquiry Panel and NHS Bristol’s Review Panel were obviously not interested in finding out, despite this being a matter of public interest, particularly to women choosing where to go for gynaecological services.  According to University Hospital’s Histopathology Inquiry Report, the Royal College of Pathologists made these comments about the diagnostic quality of some of the Gynaecological cases they reviewed:

a. “Unable to comment because of absence of previous slides for comparison” – unsurprising as University Hosptital has confirmed that there was no external, independent quality assurance of the slide selection process.

b. “Incomplete documentation of sampling…..assessment limited by lack of slides from previous specimens” – again lack of process quality assurance.

c. not “adequately considering the possibility of a rare variant”

d. “reviewers are unanimous about the nature of this error in the original report, but reviewer ID 5 comments …..an uncommon lesion with which non-specialist pathologists might not be familiar”. The error was made by UHBT’s Lead Gynaecological Pathologist. (case BH07-11538 Bristol Histopathology Report).

e. “the stage of the tumour has been incorrectly assessed” Correct staging of cancer informs patient treatment plans. If incorrect, it can adversely affect the patient’s prognosis.
These comments were made about a sample of errors identified by NBT over a two year period and tell us nothing about the many cases over the years that were never reviewed by North Bristol.

University Hospital’s Histopathology Inquiry Panel’s Report says on page 56, paragraph 2.32 that, as far as it is aware, no concerns have been raised about gynaecological pathology reporting since June 2008, but acknowledges that this may be because specialist review of gynaecological cases ceased then.

Pity the women of Bristol, North Somerset and South Gloucestershire who put their trust in University Hospital’s Gynaecological Cancer services and have no idea that, according to its Inquiry Panel, specialist review of gynaecological pathology ceased several years ago.

How long this is set to continue, we do not know because University Hospital, North Bristol and NHS Bristol will not publicly discuss their detailed plans to implement specialist histopathology.

Users of Bristol’s breast services, some of whom will also be users of gynaecological services, may well wonder about the implications for them of the twenty month delay between Ms Lee knowing about pathology concerns on 15th October 2007 and Ms Evans eventually obtaining specific case details from NBT on 24th June 2009.

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