26 April 2010
The National Patient Safety Agency (NPSA), the body that manages a national safety reporting system, has published a report, Delayed diagnosis of cancer: Thematic review, that presents the findings of a project at the NPSA which was designed to explore issues of patient safety around delayed diagnosis of cancer. The report reveals some worrying findings which could affect the health of thousands of cancer patients in the UK.
The report identifies a number of errors in patient care that are familiar to clinical negligence lawyers at Leigh Day who have represented many people in litigation about cancer. In particular the report notes that doctors have failed to identify early signs of cancer leading to a delayed diagnosis and treatment of cancer which often results in the death of a cancer patient. The report also notes that patient’s tissue samples have been mixed up, that some patients were wrongly given the all-clear and that diagnostic tests were delayed because of staff and equipment shortages.
Leigh Day has been involved with cancer cases since the firm’s inception. Two high-profile examples were the cases of young mothers Ruth Picardie and Beth Wagstaff, two young women who died when their breast cancer was not picked up early enough. Cases are still referred to Leigh Day that show that medical staff continue to make mistakes about the early signs of cancer, with devastating consequences for the patient and their families.
Cervical cancer case
A tragic case recently settled by Sally-Jean Nicholes, a partner in the clinical negligence department at Leigh Day, demonstrates repeated errors in the care of one patient.
The patient died because signs of her cervical cancer were missed not once, but four times between 1998 and 2004. In 1998 her smear test sample was sent for analysis and was reported to be normal. In fact the sample was not adequate for testing and the laboratory should have reported that fact so that another sample could have been obtained and tested.
At the next routine recall, in 2002, a sample was sent to a different laboratory. The sample was reported to be normal. In fact it was abnormal and our client should have been referred for further investigation and treatment. In 2003 and 2004 our client had detailed abdominal scans in the course of treatment for fibroids. On each occasion the radiologist failed to notice abnormalities on the scans and refer his patient for further investigation and treatment. By the time the cancer was diagnosed, in 2005, it had developed to an advanced stage. If appropriate care had been given between 1998 and 2004, the disease would not have progressed and become fatal.
Of the 508 cases examined in detail in the report, it was found that 177 patients were harmed. Two died, 25 suffered severe harm, 52 moderate harm and 88 low harm. Of a sample of 150 patients, 37% experienced delays of up to three months, 38% of more than three months and some had delays of three years. The government estimates that 10,000 die each year because of late diagnosis of cancer.
The report makes five broad recommendations:
- Development of an accessible diagnostic tool for use in primary care.
- Identify, review and disseminate good practice in the process of ordering, managing and tracking tests and test results.
- Review and develop methods for empowering patients who may be on a cancer diagnostic pathway.
- Develop a model for stronger leadership and improved patient safety reporting and learning, including Significant Event Audit (SEA), at a local and national level.
- Develop indicators of delayed diagnosis for routine monitoring.
Peter Walsh of the patient safety charity Action Against Medical Accidents said:
"Misdiagnosis of diseases generally and cancer in particular is a huge issue in terms of patient safety, leads to people losing their lives and having their lives shortened and isn't given the priority it deserves."
Sally-Jean hopes that action will be taken as a result of the findings and recommendations made and that the tragic consequences of errors being made in cancer care service in the UK, despite the widespread publicity when things go wrong, will be a thing of the past.
For further information please contact Sally-Jean Nicholes on 020 7650 1200.
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