Action plan to stop cancer blunders; THREE PATIENTS DIED AFTER RESULTS ERRORS.

Byline: STEVE BAGNALL

HEALTH chiefs have unveiled an action plan to stop blunders which saw people with cancer mistakenly given the all-clear.

Wrexham Maelor Hospital was at the centre of a scandal where nearly 2,450 wrong results, mostly involving cancer patients, were given by the histopathology department over three years. As a result of the blunders three patients died after they were told they didn't have cancer when they did.

North Wales NHS Trust chiefs are now looking at tightening up double checking procedures of results to ensure any falling through the net are minimised. It was recognised there were major staffing pressures to cope with demand and the trust was investigating ways to manage workloads better. The action plan report underlined double checking of all histopathology cases was simply not possible.

Another problem was the size and layout of the histopathology department, which trust chiefs acknowledged needed to be remodelled to make it more efficient.

They also want to utilise the current remodelling of pathology services across North Wales under one umbrella, to spread the load and manage cases more efficiently.

A report to the NWNHST said: "The trust should assure itself that it has robust systems in place for checking that medical and other professional staff are registered, competent to perform the specific tasks they undertake and regularly update their knowledge and skills to maintain their competence."

It added: "The focus of attention to date has been to increase double checking of cases where possible. Inevitably, this has led to a reduction in performance - expressed as time taken to report individual cases.

"Work is ongoing to more accurately measure workload to inform the job planning process and accurately determine service requirements." In all, 11,671 tissue samples had to be re-examined. They'd all been reported as benign by consultant histopathologist Dr Roger Williams between October 2004 and September 2007.

An independent Healthcare Inspectorate Wales investigation found 181 (1.6%) cases where an error would definitely affect clinical management; 479 (4.1%) errors which had the potential to affect clinical treatment; and 1,799 (15.4%) classed as minor discrepancies.

A further 1,800 patients got wrong results but they had little clinical significance, the HIW report said.

NWNHST is now facing a number of potentially expensive legal actions from misdiagnosed patients, although trust chiefs would not say who many.

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CAPTION(S):

Dr Roger Williams, the man at the centre of the results blunders at Wrexham Maelor