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The family of a mother who died from cervical cancer after twice being wrongly told she had negative results have been awarded undisclosed damages. The misreporting of Louise Gleadell's cervical screening results was admitted by University Hospitals of Leicester NHS Trust following her death aged 38 in March 2018. An internal review in 2017 found the samples, taken four years apart, were not good enough to produce reliable results but neither Ms Gleadell - a mum to three boys - nor her relatives were told about the "inadequate" samples while she was still alive. Her family have now been given an undisclosed payout, with the trust apologising for its mistakes that had "devastating consequences". Ms Gleadell, from Cossington in Leicestershire, was diagnosed with cervical cancer two years prior to her death. It was, by that stage, too late to have surgery. Two cervical screening tests, carried out in 2008 and 2012, were misreported to her as negative. It meant that over a four-year period, she had been given false reassurance about her health when she was developing cervical cancer, and the opportunity to treat pre-cancerous cells passed. Ms Gleadell's sisters, Laura and Clare Gleadell, say their grief has been compounded by knowing that their sister's death was avoidable. Laura, 43, said: "Her death was preventable and that for us is ultimately really hard. "It would not have developed into cancer had she been recalled in either 2008 or 2012. "If she had had treatment for cell abnormalities before it even developed into cancer, she would not have died." Read full story Source: BBC News, 6 April 2025

Repeated failings in the way scans are read are leading to delays in cancer diagnosis, unnecessary operations and avoidable deaths, England’s Health Ombudsman has warned. Since publishing a report four years ago which highlighted mistakes in the way digital images are read and used as a diagnostic tool, the Parliamentary and Health Service Ombudsman (PHSO) has upheld or partly upheld more than 40 cases in which similar failings were found. The most common issues are doctors failing to identify an abnormality, scans not being carried out or delayed, and results not being properly followed up. Examples of the impact of these failings include a 10-month delay in cancer being diagnosed which significantly harmed the person’s chance of survival. In another case, serious pelvic sepsis was not identified which led to an avoidable death, and in a separate case, a missed ankle fracture led to an avoidable operation. The Ombudsman is calling for greater learning when things have gone wrong to prevent the same mistake being made. Read full story Source: PHSO, 20 March 2025

A woman whose mother died five years after a cancer misdiagnosis is calling for second opinions on oncology scans to be made mandatory. Louise Hickman, from Ipswich, was told in 2019 that a mass removed from her ovary was benign and that she would not require any further treatment. But in 2022, the “kind and caring mother” was diagnosed with ovarian cancer after she returned to Ipswich Hospital with worsening symptoms. Later tests confirmed her initial cyst found three years earlier had indeed been cancerous and in July 2024, she passed away, aged 47. Her daughter, Chloe, said she believes her mother’s outcome may have been different if she was correctly diagnosed in 2019, and is now campaigning to make it mandatory to have oncology scans checked by two experts. A report issued to Ms Hickman and her family by the East Suffolk and North Essex NHS Foundation Trust following her mum’s death accepted that the 2019 cyst should have been “adequately sampled and referred for an expert opinion” at the time. A clinical opinion included in the report also stated that the “missed diagnosis with delay in treatment caused significant harm”. She has launched a petition calling for the government to implement “Louise’s Law”, which would make it mandatory that benign oncology scans are sent for a second expert opinion. Read full story Source: The Independent, 19 March 2025

A coroner has issued a warning about the role of physician associates in NHS hospitals after a woman with severe abdominal problems was wrongly diagnosed as having a nosebleed and died four days later. The family of Pamela Marking, 77, were under the mistaken impression she had been seen by a doctor when she was examined in an emergency department, rather than a physician associate (PA) with far less training. Surrey assistant coroner Karen Henderson has written to 12 health leaders or bodies including the UK health secretary, Wes Streeting, and NHS England expressing concerns about the “limited training” PAs have and the lack of public understanding about their roles. In a prevention of future deaths report, Henderson said Marking was taken to East Surrey hospital in Redhill on 16 February last year after she vomited blood-stained fluid and had a tender abdomen. The coroner said the PA who saw her had “a lack of understanding of the significance of abdominal pain” and sent her home the same day. Marking deteriorated, returning to the hospital two days later. She underwent surgery for complications arising from a femoral hernia but died on 20 February 2024. Henderson said the PA had acted independently in the diagnosis, treatment, management and discharge of Marking without independent oversight by a medical practitioner. The coroner said: “Given their limited training and in the absence of any national or local recognised hospital training for physician associates once appointed, this gives rise to a concern they are working outside of their capabilities.” Read full story Source: The Guardian, 27 February 2025 Related reading on the hub: Physician associates: What are the patient safety issues? An interview with Asif Qasim Partha Kar: We need a pause to assess safety concerns surrounding Physician Associates Prevention of future deaths report: Susan Pollitt (8 August 2024)

A woman has expressed her anger after being diagnosed with cervical cancer more than two years after her smear test result was incorrectly recorded as normal. Amie Wood, 39, from Bewdley, Worcestershire, had a smear test that was reported as negative by the Royal Wolverhampton NHS Trust in October 2019. Although negative, it showed high-risk human papillomavirus (HPV), a virus that can lead to cancer, the HPV persisted and she was subsequently diagnosed with cervical cancer in January 2022. The NHS trust said it expressed its regret and apologised to Ms Wood. Following her diagnosis, Ms Wood had a hysterectomy. Ms Wood said she suffered increased anxiety about her health, and felt unable to return to her part-time second job as a personal trainer. "To be diagnosed with cervical cancer and undergo a hysterectomy was heartbreaking enough, but then I found out that my smear results had been misreported and it could have all been avoided," she said. Read full story Source: BBC News, 28 January 2025

Eight women whose smear tests were misread by screeners went on to develop cancer, a major review into cervical screening at the Southern Health Trust has found. A further 11 women's slides were found to have pre-cancerous changes in the cells when they were reviewed and had to receive treatment. All these women had either pre-cancerous changes to their cervix or were diagnosed with another significant gynaecological condition when their smears were reviewed. The review was triggered when the diagnoses of three women were investigated as a Serious Adverse Incident. Two of the women, Lynsey Courtney and Erin Harbinson, have since died. More than 17,000 were approached to have their smear tests rechecked. The examination of cancer screening at the Southern Health Trust over 13 years found that many women were failed after some screeners underperformed and went unchecked by management for years. Stella McLoughlin from the campaign group Ladies with Letters described what had happened as unforgivable and called for a public inquiry. "This has been an absolute scandal from start to finish and was allowed to go on for 10 years," she added. "Smears being misread, people not being held to account, screeners not being managed properly - all of this is affecting real people." Read full story Source: BBC News, 11 December 2024

Hundreds of patients are being contacted over potentially incorrect results at a second NHS trust, as more laboratories report concerns over diabetes tests, HSJ understands. Bedfordshire Hospitals Foundation Trust was the first to report an issue over blood tests earlier this year, saying up to 11,000 patients may have received the wrong results – including a misdiagnosis of diabetes. But the Medicines and Healthcare Products Regulatory Agency has confirmed to HSJ that other laboratories across the country have reported concerns over the same device, which measure glucose control. The Hb1AC blood test is used to diagnose diabetes and prediabetes, as well as manage existing conditions. One affected trust is Maidstone and Tunbridge Wells FT, which said around 1,500 patients had been identified for a retest following a technical issue affecting results in July. A spokesman said the problem was escalated to the supplier as soon as possible, and that affected patients would be contacted by GPs. Read full story (paywalled) Source: HSJ, 27 November 2024

Tuesday 17 September 2024. Another year, another World Patient Safety Day. This years theme “Improving diagnosis for patient safety”. Last years' report by the World Health Organization https://www.who.int/publications/i/item/9789240095458 first introduced the theme and talked about the need for multifaceted interventions rooted in systems thinking, human factors and active engagement of patients, their families, health workers and healthcare leaders. Improving healthcare processes that will result in improvements to diagnosis requires action at every level of the health system and looking at this years' calls to action https://www.who.int/campaigns/world-patient-safety-day/world-patient-safety-day-2024/calls-to-action leadership is both implied and front and centre. Focusing on these calls to action, here is what the campaign suggests individuals/entities across a range of settings can do to help improve patient safety in diagnosis. Patients, families and caregivers are - be informed, involved, and proactive in your diagnosis Be actively engaged in the diagnostic process and with your health care team: share accurate and comprehensive information about your symptoms and medical history; make sure you understand the diagnostic process, your illness’ or symptoms expected progression, and next steps; check your information is up-to-date, and keep track of your symptoms, medical visits, tests and treatments. Share your questions and concerns: don’t be afraid to ask questions; speak up, ask about alternative options or seek a second opinion if you need to; share your experiences and contribute to making diagnosis safer for others. Health workers providing clinical care - make diagnostic excellence integral to your daily practice Keep focussed on the person at the centre of the diagnosis: listen to your patient, ask them about their concerns and tailor the interventions to their needs; take a careful and thorough history and physical examination of your patient; talk openly and empathetically with your patients, and encourage them to ask questions. Leverage available technology, tools, and tests to reach a diagnosis. Be a good team player and contribute to a safe and collaborative professional environment, where information is shared in a timely manner. Keep learning: participate in regular training and seek feedback from your peers and patients; contribute a culture of continuous improvement by sharing best practices, and information about errors and near misses with peers. Healthcare facility leaders and managers - implement safer systems to improve diagnosis, support your clinical teams and empower patients Empower the health workforce through policy, culture and practice: ensure adequate staffing, resources and regular capacity development; make sure quality and well-maintained tests and technologies are available; implement and monitor the use of diagnostic safety guidelines, protocols and practices to ensure errors are minimised; promote a culture of continuous learning and safety, and take action to address problem areas; establish a conducive, collaborative and safe work environment free from distractions. Continually seek feedback from patients and their families and reserve space for advocates on advisory bodies. Celebrate diagnostic excellence within your teams. Policy-makers and programme managers - champion diagnostic excellence in health policy Prioritise patient safety in policy, legislation and regulation: ensure that appropriate guidelines and protocols to support diagnostic processes exist at a national level and are implemented; provide the necessary budget, staff, training and access to tools and technologies for national health systems. Establish national collaboration mechanisms to sustainably engage stakeholders. Promote accountability through monitoring and evaluation mechanisms, and ensure health leadership prioritize transparency. Set up national knowledge-sharing systems and encourage continuous learning. Invest in research into diagnostic errors, patient harm and the development of diagnostic tools and technologies. Patient organizations and civil society - advocate for quality and safe diagnosis Champion diagnostic safety in health policy and practice: work with patients, policy-makers and health care leaders to build health systems that deliver correct and timely diagnosis; facilitate patient advocacy and support their role in promoting and improving diagnostic safety; work with policy-makers, academics, health care leaders, health workers and patients to help identify areas for improvement. Contribute to the development of educational and training resources for health workers and patients. Diagnostics and medical devices’ regulators, manufacturers, innovators and managers - innovate for smart solutions and diagnostic excellence Drive research and development for diagnostic tools and technologies. Ensure diagnostic solutions meet the highest standards of safety, quality, and reliability. Create user-friendly products and instructions and provide regular training for health workers and patients. Collaborate with patients, health workers and health care leaders to build products tailored to the needs of end-users. I'm a strong believer in the power of campaigns. They act as a tool to raise awareness on important matters and trigger action that will result in change and improvement and there is evidence that they can have an impact on patient outcome. Before the end of 2024 there will be many more awareness days and weeks all of which will use campaigning to get their messages across in the noisy world of health care. It will be interesting to see the evaluation of WPSD 2024. More on this in due course.

Have you or someone you know been affected by a: delayed diagnosis incorrect diagnosis missed diagnosis? Errors can happen at every stage of the diagnostic process and can happen in all healthcare settings. In some circumstances the impact is life-changing. If you have insights to share around diagnostic error and the impact on patient safety, please comment below (sign up first here, for free). Or you can contact us directly at [email protected]. This post has been published as part of our World Patient Safety Day activity, with the 2024 theme of Improving diagnosis for patient safety. #WPSD, #WorldPatientSafetyDay, World Patient Safety Day 2024