An NHS Manager Misdiagnosed

Bristol Histopathology

Editor’s Note: This story comes from the husband of a woman who died of breast cancer, after an avoidable error with a pathology slide.  As told to Local Authority Councillors of Bristol, North Somerset and South Gloucestershire. Jane Hill was a senior manager at North Bristol NHS Trust.

My name is Reg Hill.

My late wife, Jane Hopes, is a victim of misdiagnosis by a consultant histopathologist who still works at the Bristol Royal Infirmary (BRI), managed by University Hospitals NHS Foundation Trust.

I am here today to tell you Jane’s story as an example of how she and other patients have been betrayed by senior NHS Managers, medical directors of both Trusts (University Hospitals and North Bristol), senior consultants in both Trusts, University Hospitals Bristol’s Histopathology Inquiry Panel and the Royal College of Pathologists.

Jane was employed by North Bristol NHS Trust as Assistant Director of Planning and Cancer Services. She was betrayed by her own colleagues because they did not tell her the truth that she had been misdiagnosed, thereby depriving her of the opportunity to seek independent, professional advice when she was told that she had breast cancer and that it had spread.

In 2001 Jane attended Avon Breast Screening for a routine mammogram. An abnormality was seen and Jane had a core biopsy. The biopsy was reported as benign by the BRI’s Lead Breast Histopathologist. Jane was discharged and told she would be recalled for a routine mammogram in three years.

In 2003 Jane developed symptoms and was seen at Frenchay Hospital. Cancer had developed at the site where the biopsy had been taken two years earlier. Her surgeon did not tell her that North Bristol Pathologists had checked the core biopsy slides reported in 2001 by the BRI and found that they showed she had pre-invasive breast cancer, which was curable.

Jane died of incurable breast cancer in November 2004.

In spring 2010, a journalist from the Sunday Telegraph appeared on my doorstep and asked me whether I knew that Jane’s case was being reviewed as part of an Inquiry into misdiagnoses at the BRI. I did not know. Neither Jane’s former NHS colleagues nor the Inquiry Panel had the decency to contact me and other families affected to ask for permission for cases to be reviewed and to invite them to give evidence to the Inquiry Panel.

In summer 2010, at my request, I gave evidence to Jane Mishcon’s Inquiry Panel, which, with hindsight was an utter waste of time. I asked the Panel to ensure that double reporting of breast histopathology was implemented in the Bristol area. My request was ignored. Double reporting for breast pathology is not mandated.

In October 2009, University Hospitals and North Bristol Medical Directors, Sheffield and Burton, compiled a table of misdiagnosis cases for review. It was sent to Jane Mishcon’s Panel. They said of Jane’s case:

Patient died. Carcinoma in situ missed diagnosed as benign.”

However, in the Inquiry Report, Professor Furness, President of the Royal College of Pathologists dismissed my wife’s death with these words:

The expert reviewers concur that the original report represents a diagnostic error, but it is one that (to quote reviewer ID eight) a small proportion of histopathologists might make. It is notable that the original report gave no hint of uncertainty.”

Is Professor Furness so uncaring that he regards an avoidable death as an acceptable error to be made by the lead histopathologist for Avon Breast Screening, serving an eligible population of 130,000 women?

Mrs Calland,

who has incurable Lymphoma, was misdiagnosed by the same histopathologist who misdiagnosed Jane. By contrast, Mrs Havercroft,

received an accurate breast cancer diagnosis in 2003 from the North Bristol breast histopathology team. She was diagnosed and treated correctly and is alive and well eight years later.

In 2005, a North Bristol lung physician wrote this to Dr Martin Morse, former Medical Director of North Bristol, “Our patients are being told that, amongst other things, they have cancer when they haven’t and are also being reassured that they don’t have cancer when they have. It is then us that have to pick up the pieces. Where would we wish specimens from our own lungs or those of our relatives to be sent? All we are really asking is for our patients’ specimens to be sent directly to the most appropriate pathologist.”

Mrs Havercroft’s specimens were sent directly to the most appropriate pathologist and Mrs Calland’s and my wife’s were not.

The Histopathology misdiagnosis concerns cover lung, gynaecological and skin histopathology as well as breast, and span at least 10 years. How many more Catherine Callands and Jane Hopes have unnecessarily been harmed and died during that period?

I have discovered that four years ago a North Bristol pathologist stood in a Joint Health Scrutiny Meeting at Bristol Council House in front of at least 10 senior NHS managers and doctors, including his own Medical Director. He said of BRI pathology that some aspects of it were not up to standard. It is clear that none of these highly paid public servants took his concerns seriously and properly investigated them.

University Hospitals’ Inquiry Panel, the Royal College of Pathologists and regulators Monitor and the Care Quality Commission did not investigate them properly either.

Two of the doctors who blew the whistle on unsafe histopathology, and whom members of the public believe were appallingly and unfairly undermined in Jane Mishcon’s Inquiry Report, no longer work in Bristol.

This is a tragedy. They are the only doctors who did not give in when things got tough, because of their integrity and high standards of care for patients.

Concerns about histopathology misdiagnoses were first raised in public at Health Scrutiny Meetings in 2007 and about the Histopathology Inquiry in January 2011. Yet senior managers and doctors at NHS Bristol, University Hospitals and North Bristol still escape public accountability for their failings and the debacle of the Histopathology Inquiry.

How many more years have to pass, how many more people have to be harmed and die and how many more excellent doctors have to be driven away from Bristol before elected representatives (Councillors and Members of Parliament) and local involvement networks (LINks) take action to ensure that the NHS is held to account for its betrayal of patients and the public?

I request local authority Health Scrutiny Committees to insist on double reporting for all breast pathology and a full, independent external investigation to establish the truth about the histopathology misdiagnoses and the reasons why so many senior people failed to act on them.

Please act without delay to protect the people of Bristol, North Somerset and South Gloucestershire.

Note: Local Authority Health Scrutiny Committees have powers to make recommendations to providers and commissioners of NHS services based on evidence they have received or gathered.

LINks comprise individuals and groups from the community. Their role is to find out what people want from Health and Social Services,  monitor local services and to use their powers to hold those services to account.












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