Yesterday’s MailOnline featured Julie O’Connor and her family describing failings in care and delays in diagnosis which led to her untimely death at the age of 49 from cervical cancer. Just days before her death Julie and her family created a video highlighting her suffering to show the North Bristol Trust the impact of what they had done and to emphasise their call for a wider review into the cervical screening programme provided by the Trust. The family are determined to ensure that Julie’s case is not considered by the Trust in isolation, but that a thorough review is carried out of all aspects to the service including a review of past patients' results.
Proper training and oversight is important in all areas of medicine and with screening programmes this is particularly the case given the numbers of patients involved.
But when does an incidence of poor care signify systemic failure? To determine this there should be a detailed independent review taking into account a thorough appraisal of all the facts, the judgments and decisions made and why, and the competencies, training and supervision of all concerned. Such a review is likely to need input from several different professional bodies in a collaborative fashion and may include reviews of some former patients in addition to Julie O’Connor.
In one cervical cancer case I dealt with, an abnormal smear result had merely been filed and not communicated nor acted upon. It was not until the patient re-presented a couple of years later that a review of the records revealed that an abnormal smear result was on file. This was indeed a systems error, but one which was limited to part of the process, namely the communication between the laboratory and treating clinicians, rather than one which involved a cascade of errors and judgment. In that case the Claimant underwent more extensive treatment than would otherwise have been the case and had a reduced life expectancy. The claim was settled taking into account the difference which the delay in diagnosis made to both treatment and outcome.
Another case of systemic error I dealt with related to immunosuppressants at a Trust in Cambridgeshire. On this occasion there was an independent review which also involved consideration of previous patients’ records. In that case, it appeared that a consultant in charge of a small highly specialised unit was not himself being subject to any review and was employing non-standard practice. To the Trust’s credit, it contacted each of the patients involved and it was only then that my client realised that she had not received proper care. The Trust concerned also introduced proper systems of management going forward to ensure that a team approach in the unit was taken. The claim was settled on the basis that the Claimant had suffered unnecessary treatment over a number of years, and took into account the impact of that treatment on both quality of life and earning power.
It is clearly in the interests of both trusts and patients that systemic failings as well as individual mistakes are investigated. It is to be hoped that the investigation into the North Bristol Trust cervical services is indeed wide ranging given the devastating nature of the disease, the importance of fostering patient trust and confidence, and the women who, like Julie O’Connor may have been let down.
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