Test results mislaid of patient who died from cancer
HOSPITAL staff missed the chance to save a cancer patient’s life after they mislaid his test results, according
HOSPITAL staff missed the chance to save a cancer patient’s life after they mislaid his test results, according to an official report.
Tony Stevens, who used to manage the former Jet petrol station in Reading Road, Henley, died on New Year’s Eve, aged 48.
But he could have lived if his illness had been discovered sooner.
In January 2010, Mr Stevens underwent an ultrasound scan at the Royal Berkshire Hospital in Reading after reporting pain in his lower body, shortness of breath and blood in his urine.
This revealed early signs of a tumour on his right kidney.
However, according to the report by the hospital trust, the findings weren’t sent to his consultant and he was never contacted for a follow-up appointment.
Mr Stevens, from Dunsden Green, assumed nothing was wrong because his symptoms cleared up by themselves.
He had been in a motorcycling accident a few months earlier and assumed they were related.
But in July last year, he was referred back to the hospital for unexplained weight loss and pain throughout his body. Tests showed the tumour had grown and spread to his lungs, lymph nodes, bones and brain.
He was told there was no hope of treatment and given six months to live.
He was referred to the Sue Ryder hospice in Nettlebed, where he spent his final days.
His family are suing the Royal Berkshire NHS Foundation Trust for negligence, saying the diseased kidney could have been surgically removed in 2010. They claim his chances of survival at that stage were above 90 per cent.
His lawyers lodged a writ at the High Court in London shortly before his death and a hearing is scheduled for Monday.
The trust investigated Mr Stevens’s case, which it classed as a “serious incident” with “catastrophic” consequences.
It says it has tightened its procedures to avoid a repeat.
The report, which the Henley Standard has seen, says that Mr Stevens’s first scan was apparently requested by an orthopaedic surgeon whom he had been seeing since his crash.
However, it could have been booked in the consultant’s name by clerical staff and he might not have known about it so would not have made a note to chase it up.
Furthermore, radiology requests were not processed electronically at the time. Instead, request forms were filled out for scans and the results returned via the internal post.
The report says there is no evidence that Mr Stevens’s results ever arrived.
His ultrasound scan showed a “complex mass” about the size of a ping-pong ball on his right kidney which could either have been a swollen blood clot or a tumour.
The radiologists assumed it was the former caused by his accident and did not flag it up as a high priority.
If the orthopaedic surgeon had seen it, he was likely to have referred Mr Stevens to a urologist for more tests.
A copy of the scan was kept in the X-ray department and the error was discovered when Mr Stevens had another ultrasound scan last year.
By this stage he had multiple growths in his lungs and neighbouring lymph nodes, a large tumour destroying his ribs and pressing on his chest nerves, several growths attacking his spine and a large “destructive” bone deposit in his right kidney stemming from a “very large” renal cell cancer. He had been suffering breathing problems since 2013 and by 2015 had muscle wastage, loss of appetite, night sweats, difficulty swallowing and stomach upsets. He had lost more than a stone and felt pain whenever he moved.
Mr Stevens complained to the trust in September and chief executive Jean O’Callaghan promised an investigation.
She offered her “sincere apology” for the “severe delay in diagnosis and Â treatment”.
The report concludes the oversight resulted in “terminal illness and loss of opportunity for curative intervention”.
It recommends a “focus on the lack of review of a radiological investigation” and says: “All the root causes lead to a similar conclusionâ€¦ that had the scan result been seen by a clinician, the outcome in this case would have been completely different.
“In discussion with consultant urologist it is likely that, had this been seen and escalated in 2010, the possible treatment would have been curative surgery.”
The hospital introduced an electronic referral system in September and radiologists must now raise concerns directly with a patient’s consultant.
The trust is to present its findings at a board meeting.
Mr Stevens lived in the Henley area all his life and at the time of his diagnosis was a part-time caretaker at Eye and Dunsden village hall, which once housed the village school he attended.
In his final weeks, he discussed his experiences at the hospice with the Henley Standard to encourage donations to Sue Ryder’s Christmas appeal.
The campaign smashed its £7,000 target and instead made more than £21,000. Mr Stevens was told the good news shortly before he died.
If his legal action is successful, any payout will go to his estate for the benefit of his heirs.
The trust said it could not comment for reasons of patient confidentiality and because the case was the subject of legal proceedings.