Tuesday, 1 December 2009

Mother dies after cancer screening machine blunder

By Jason Lewis
Last updated at 1:42 AM on 29th November 2009


One woman has died and hundreds of other cancer patients put at risk after a crucial machine used to test for the best way to treat the killer disease developed a fault that was not repaired for at least a month.

The NHS hospital at the centre of the blunder failed to tell patients their results may have been wrong due to the broken equipment.

It also did not report the incident to the medical authorities – an apparent breach of Department of Health rules designed to protect patients and alert doctors to problems.

Last month, mum Tracey Kindley, 43, died of breast cancer after learning her treatment had been based on inaccurate test results.

Tracey Kindley

Tracey Kindley with her son Max. She died last month after learning her cancer treatment had been based on inaccurate test results

She was being treated at a private hospital in North London after she discovered a suspicious lump in March 2005.

Her doctors performed a biopsy and sent it to a local NHS Trust’s pathology department, which confirmed her cancer. But one of the machines used at the Queen Elizabeth II Hospital, in Welwyn Garden City, crucial in assisting her doctors in deciding the best treatment for the cancer, was not working correctly.

The machine – used to test hormone levels – gave a ‘false negative reading’ for oestrogen, meaning she was not prescribed certain life-saving drugs because it was thought they would have no effect on her cancer.

Her doctors spotted the error only when she failed to respond to treatment and the cancer spread.

Q E II hospital

One of the machines used at the Queen Elizabeth II hospital was not working correctly

The doctors ordered new laboratory tests on the original biopsy and these results showed very high oestrogen levels in the cancer cells, alerting them to a major error.

Health service managers at the Queen Elizabeth II ordered checks and discovered the machine had developed a fault around the time of the tests on Mrs Kindley.

A service report on the equipment shows a ‘critical repair’ was carried out on May 6, 2005. The managers claim the machine was ‘fixed within days’ of the problem being identified, but crucially Mrs Kindley’s tests were carried out on April 8 – almost a month before the fault was spotted.

The East and North Herts NHS Trust, which oversees the hospital, re-examined the results of other patients whose samples were tested on days either side of Mrs Kindley’s.

However, an internal investigation concluded the incident was a ‘one-off’ and that despite testing hundreds of patients during the period, no other patients could have been affected.

The conclusion meant patients tested when the machine is known to have been malfunctioning – a period of around four weeks – were never alerted that they, too, may have been given the wrong results.

In the weeks before her death, Mrs Kindley began a legal action against the hospital. Her lawyer Hugh Johnson, of Stewarts Law, believes that had she been given the right treatment, she would have had a 70 per cent chance of making a full recovery.

In his letter to the Trust, Dr Nihal Shah, Mrs Kindley’s consultant clinical oncologist, wrote that she ‘had concerns that a similar scenario does not arise for other patients’.

Mrs Kindley died on October 28. Yesterday, her husband said he blamed the test errors for his wife’s death. ‘I believe they robbed me of my wife. The right results would have opened up other forms of treatment and I believe she would be with me and her son Max now.’

Last night, the Trust acknowledged the tests carried out had given a ‘partial false negative result’ and it has apologised that this should have happened. It admitted that the problem had not been reported to the Medicines and Healthcare product Regulatory Agency. ‘That decision is now being reviewed.’