Message from cancer patient failed by medics who made ‘catastrophic’ error: be careful

Posted On 05 Aug 2014 at 11:03 am
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A cancer patient whose tumour was missed by medics who made a “catastrophic and irreversible error” told future doctors they need to “be careful”.

Matthew Kershaw

Matthew Kershaw

The patient, known only as Brian, is now battling terminal lung cancer diagnosed in 2013 – but an x-ray taken three years earlier had also shown a mass which was missed.

The message was relayed in the weekly message from the Brighton and Sussex University Hospitals NHS Trust Matthew Kershaw, which can be downloaded here.

He said: “This week I want to talk about Brian. In January 2010 Brian was referred to us by his GP because he had severe anaemia. He was admitted, given a blood transfusion and various investigations were undertaken to try and establish the cause of his condition which seemed to suggest he may have had an internal bleed.

“He also had a chest x-ray because he was a life-long smoker and had recently lost weight. He was seen on the ward round the next day and as he was feeling much better and the investigations of his stomach had not found any immediate issues he was discharged home with a Digestive Diseases outpatient appointment arranged.

“Nobody followed up his chest x-ray before he was discharged. In January 2013 Brian was again referred to us by his GP this time for a cough that he couldn’t shake off.

“Again a chest x-ray was performed and this showed a mass in his lung. When the chest x-ray which was taken in 2010 was then looked at it became apparent that a smaller and less obvious mass was there at that time. The mass turned out to be cancer.

“We can never know for certain what treatment would have been possible had Brian’s lung cancer been diagnosed in 2010 as opposed to 2013, by which time it was inoperable and terminal, but what we do know is that we made a catastrophic and irreversible clinical error in his treatment and care.

“Brian came to our public Board Meeting last Monday to talk about what happened to him and how he felt about it. Not because there was anything we could say or do to change it but because the Board has overall responsibility for the safety and quality of the services we provide and we cannot claim to be upholding that responsibility unless we hear directly from patients – and particularly patients for whom the safety and quality of the care they received has not been as it should. The most telling exchange was when Brian was asked what, if he had the opportunity, he would say to a group of F1 doctors just about to embark on their hospital careers.

“He said I’d tell them to be careful and the rest is up to you – they’re your doctors. He is of course right. The extensive changes we have made to our systems and processes will reduce the likelihood of the same mistake happening again. But despite our best efforts people are fallible, they get distracted, they forget things and they make mistakes.

“That is why we need to have the courage to design systems which presume people will make mistakes and, when they do, have the courage to talk about them openly and honestly. That is the only way we will protect our patients from harm and protect our staff from human error – we have a duty to do both.

“Tomorrow we have our Quality Summit at which the Care Quality Commission will present the findings of the inspection of our services they undertook in May. When they publish the full report later in the week we will be able to share the details.

“What I can say today is that they welcomed and endorsed our approach to the inspection which was to be proud of the things we do well, open and honest about the things we don’t and clear about what we are doing about them.

“And I hope my sharing of Brian’s story demonstrates that this not just rhetoric but an approach I am committed to and want us to apply to everything we do.”

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