Monthly Archives: May 2016

East Lancashire Hospital Health Trust chairman misleading family and Graham Jones MP

When East Lancashire Hospital Health Trust chairman, Kevin McGee, ignored requests for answers and information (on behalf of the family) from Graham Jones MP, Graham wrote directly to the Department of Health in an effort to get our family some answers.

After months of ignorance, finally Kevin McGee was forced to provide some answers and information. We received this by letter in April 2016.
Almost every single question we asked, has been reworded or replaced by a different question then quoted by Kevin McGee in the letter, to which Kevin McGee has offered selective information (or a scenario of how it should be) as his answer (I use the term “answer” loosely!).

Kevin McGee is hopelessly trying to mislead both the family and Graham Jones MP.

“Was an HPB MDT meeting held on 12th September 2014?
We can confirm that there was an HPB MDT meeting held on 12th September 2014. (Dad’s) case notes indicate that his case was going to be discussed at this MDT meeting.
The cancer team have checked their MDT files again and there is no record of (dad) being deferred on the 12th September 2014 (MDT meeting). His (dad’s) first planned discussion
was 19th September (MDT meeting) and this went ahead.”

What the family actually asked:
Why did David Chang  (HPB MDT clinical lead) make false and misleading statements regarding the HPB MDT meeting not being held, that diagnosed dad with cancer on the 12th September 2014, in our face to face meeting in August 2015?
Overwhelming written evidence shows that David Chang (HPB MDT clinical lead) lied in our August face to face meeting (on record) when he said that “no HPB MDT meeting took place on the 12th September 2014”

  • Dr Mansoor (ward consultant) stated in March 2015 face to face meeting (on record) that diagnosis was made by HPB MDT at 12th September 2014 meeting.
  • Senior Royal Blackburn staff (ward doctors, nurses, dieticians, etc.) have all documented in written notes of the proposed treatment and care plan from 12th September HPB MDT meeting, that David Chang had claimed was not decided until the HPB MDT on 19th September 2014.
  • HPB MDT meeting notes show clearly that diagnosis was made at the 12th September 2014 HPB MDT meeting.
  • Dr Kaushik was present at the HPB MDT meeting of the 19th September, he had already carried out the cytology biopsy procedure (18th September), that David Chang said was not decided until the 19th September, yet never mentioned this to the clinical lead of the HPB MDT team!

Kevin McGee contradicts himself in his attempt to answer his own question;
“His first planned discussion was 19th September 2014 (HPB MDT meeting) and this went ahead”
“HPB MDT meeting was held on 12th September, his (dad’s) case notes indicate that his case was going to be discussed at this meeting”
Which one is it Kevin?
How about you answer the family’s original question Kevin?

“When were the FNA (Fine Needle Aspirate cytology) samples taken and when were they reported on to the treating clinician?
The FNA results were collected during EUS endoscopic ultrasound on 18th September 2014. The results were reported on 26th September and discussed in the MDT meeting on 3rd October 2014.”

What the family actually asked:
Why was (treating clinician) ward consultant Dr Mansoor not given the results of the FNA when they returned “No evidence of malignancy” and why was no retest ordered?

We already knew when the FNA samples were taken. It’s documented in the notes and dated. We told Kevin this.
At our March 2015 meeting, Dr Mansoor claimed (on record) that he had never been asked for the results by dad’s GP and that he had never received them.
We have since received a copy of the email sent from the critical nurse specialist (CNS) to Dr Mansoor that did inform Dr Mansoor of the results,

The negative test results Dr Mansoor claims he had never seen.

The negative test results Dr Mansoor claims he had never seen.

At our August 2015 face to face meeting with Mr David Chang (HPB MDT clinical lead) and Dr Kaushik whom took the FNA samples, they both claimed that the FNA test results were not seen until they were presented at the HPB MDT meeting on 3rd October 2014 – another lie as the email clearly shows the date when it was reported to Dr Mansoor, 29th September 2014.
The sender of the email was the CNS whom also sat on the HPB MDT meetings.
Kevin McGee tells the family (via our MP) that the results were reported to the “treating clinician” on the 26th September, he is wrong.
How about you answer the family’s original question Kevin?
Why do you see nothing wrong when Royal Blackburn’s HPB MDT clinical lead lies to the face of the family and why did ward consultant Dr Mansoor not carry out a retest?

What do you think of Dr Mansoor (treating clinician) and his claims of “never seeing the negative test results”?

“MDT membership and quoracy.
The letter from (the family) requests copies of the MDT attendance list, which has been refused on the grounds of confidentiality, but we can advise that inline with cancer peer review standards, the three MDTs were all quorate. They had attendance of the following members;

  • Consultant surgeon
  • Consultant GI physician
  • Consultant radiologist
  • Consultant histopathologist
  • Upper GI nurse specialist
  • Consultant oncologist

It needs to be clarified that quoracy is not a reflection of the MDT core membership. The meetings were quorate which has a requirement of 95% membership but the palliative care team (read: MacMillan nurses) were not in attendance”

What the family actually asked:
Kevin McGee has now given the family three different accounts of whom was present at dad’s HPB MDT meetings, via three different responses to three different people/official bodies.
Family have written evidence that ALL these accounts of whom attended dad’s HPB MDT meetings are false.
Who was the radiologist attending the HPB meetings, that over-ruled negative scans?
Who was the oncologist attending the HPB meetings?
Who was the histopathologist attending the HPB meetings?
Why were no HPB MDT administrators present? (as is required by law)

The simple way to answer the family’s question Kevin is to produce the HPB MDT attendance register for each meeting, but Kevin has blocked release of this.
Kevin tells our MP Graham Jones that it’s “on confidentiality grounds”
Kevin tells the family and the Information Commissioner’s Office that “it’s not in the public interest to release the attendance register” for dad’s HPB MDT meetings.
Which one is it Kevin?

“The meetings were quorate which has a requirement of 95% membership (in attendance)” says Kevin McGee.
Not true Kevin!
The 95% membership refers to at least 95% core membership attendance over the previous 12 month period for meetings.
I seriously doubt it is in the public interest to have “expert” staff missing from Royal Blackburn’s HPB MDT meetings.
It does not look good, when Kevin McGee (chairman of East Lancs Health Trust) does not understand the basics of how important attendance is to a HPB MDT team.

“What happened during the MDT meetings in relation to recommendations for further tests, differential diagnosis etc.
Please find an attached copy of the MDT meeting notes.”

What the family actually asked:
The three HPB MDT meetings for dad, none of them had in attendance an MDT coordinator/administrator, yet notes have been made in real time for each of the meetings.
The notes for 12th September HPB MDT are blank.
The notes for 19th September HPB MDT refer to “the previous meeting dated the 12th September.” The notes for the 19th September 2014 HPB MDT meeting are missing.
The notes for 3rd October HPB MDT meeting state “CNS has asked referrer (Dr Mansoor) to establish a retest of FNA to clarify diagnosis” – this was never done, why not?

The HPB MDT notes presented with Kevin McGee’s letter are simply edited notes that have been cut and pasted on to an “untitled page” at East Lancashire Hospital.
These notes have been falsified.
The real HPB MDT notes presented with medical records show that the information Kevin has presented as being from 19th September 2014 HPB MDT, are in fact, the notes of the HPB MDT meeting that took place for dad on the 12th September 2014. This was confirmed in person, on record, in front of witnesses by Dr Mansoor at our March 2015 face to face meeting.
There are no notes/records for what was discussed at dad’s HPB MDT meeting on the 19th September 2014.

“FNA appeared to negative for pancreatic cancer, did we share this with the MacMillan team?
Please refer to notes from HPB MDT (provided). These notes are shared with all members of the MDT meetings.”

What the family actually asked:
Why did Royal Blackburn’s HPB MDT and/or Dr Mansoor (ward consultant) not pass on the “no evidence of malignancy” FNA results to dad’s GP or MacMillan (read: specialist palliative care team)?
The family cannot access the MacMillan notes, as these are held separately from medical records and their release is being blocked by Kevin McGee and Royal Blackburn hospital senior staff.
Kevin wrote in his earlier answer to his own question that “the specialist palliative care team were NOT in attendance at any of the three HPB MDT meetings for dad.”
Now in attempting to answer another of his own questions, he claims that “the MDT notes were shared with all members of the MDT meeting.”
Which one is it Kevin?

Let me answer for you Kevin as I know it’s difficult for you to understand.

When dad was referred to MacMillan by the district nurses, they couldn’t attend or offer any treatment.
There were no positive test results for malignancy (which is needed for MacMillan to be able to give treatment from end of life packs) so MacMillan couldn’t do their job.
MacMillan phoned the family stating clearly that there was “important information missing from (dad’s file) as the hospital (Royal Blackburn) had not updated them with test results.”
We never heard from MacMillan again. Dad passed away four days later.
On the Monday 20th October 2014, GP notes (via coroner’s office) show that MacMillan nurses had chased up dad’s FNA results and only now had they been notified of “no evidence of malignancy”
Monday 20th October 2014 – triage conversation between GP and MacMillan. GP alerted to the fact that FNA now suggested chronic pancreatitis and not cancer.
21st October 2014 – MacMillan inform GP that they will not be visiting until they get correspondence back from Royal Blackburn regarding what to do next.

MacMillan never got any correspondence regarding test negative FNA test results, until they chased them up, one day before dad passed away.
Makes a mockery of Kevin’s claim that “all MDT notes are shown to MDT members.”
Why no retest?
The family still await an answer.

“Where are the cytology slides taken for the post-mortem?
No cytology slides were created as part of the post-mortem process. The slides will be in the files at ELHT and can be retrieved.
Our records contain a fax from the coroner’s office dated 27th October 2014, stating that tissues were to be disposed of. The field on the form used to record which family member had been contacted by the coroner’s office is blank”

What the family actually asked:
Where are the FNA cytology slides that we have now been promised at numerous meetings and in writing, over a year ago?
We never asked about cytology slides and if they were involved in the post-mortem process.
The coroner’s office referred to, is the deputy coroner’s office, which is located in…. you guessed it, Royal Blackburn hospital!
It surprises the family not one jot that these records have been falsified, as the deputy coroner works closely with, one Dr Richard Prescott, the pathologist who has dodged every question the family has asked for over a year and a half.
The very same Dr Richard Prescott that failed to inform the East Lancs Chief Coroner that he sat on the Royal Blackburn hospital’s HPB MDT meetings that diagnosed dad and declared himself “completely independent from the living side of the hospital” and fit to carry out dad’s post-mortem.

That the fax contains references to “disposing of the tissue” and that no family member has been recorded as agreeing to this, is no surprise.
That’s because it did not happen, this was NOT the wishes of the family at any point in time.
Once again, standard practice has been forgotten. I wonder why that is?

“What was Dr Prescott’s findings based on?
Dr Prescott’s post-mortem findings were based on the naked eye observations and proven beyond doubt in the histological samples taken”

The family didn’t even ask about this?
How strange, chairman of East Lancs Health Trust, Kevin McGee, is now making up his own questions and answering them on behalf of the coroner’s office, via an MP?
Small problem Kevin, pancreatic adenocarcinoma is a cancer – Bronchopneumonia is an infection, the two are not related, in that you do not develop bronchopneumonia from cancer, you develop bronchopneumonia from AN UNTREATED INFECTION!
Maybe if Royal Blackburn senior staff had treated dad’s diabetic symptoms (that’s presuming they didn’t have an ulterior motive for leaving it untested – as opposed to standard practice of testing for it – say, to massage their “expected death” figures?) then it would have been picked up on much earlier?

Seeing as Kevin McGee is so qualified to answer on behalf of a pathologist, who is answerable to the Chief coroner, I would have thought Kevin would have known this?
Once again East Lancs Health Trust staff giving “expert” opinions on medical conditions they are not qualified to give… shame histopathologist Dr Richard Prescott who sits on Royal Blackburn’s HPB MDT (and carries out post-mortems for East Lancs Chief Coroner without declaring his vested, conflict of interest) didn’t refer dad’s case to a QUALIFIED member of staff at HPB MDT level, instead of over-ruling negative test results in cytology and medical opinion of chronic pancreatitis from Dr Robin Moseley (clinical lead at Addenbrookes’ cancer hospital and a practising cytopathologist) when he wasn’t qualified to do so!

What Kevin fails to recognise at any point in time, is that post-mortem findings are retrospective.
They have no bearing on dad’s case because at the time of treatment (if you can call ignoring an elderly man and his obvious diabetic symptoms for weeks until he passes away, treatment) there were no positive test results.
The scans and biopsy results all returned negative, suggesting chronic pancreatitis.
Dad’s treatment was based on inaccurate assumptions of senior HPB MDT staff at Royal Blackburn hospital.

They knew that dad was weak, they knew that dad was a COPD sufferer, yet still discharged him with midazolam injections, to “calm him down” despite midazolam being very dangerous in causing respiratory arrest in COPD sufferers.

“Meeting with Dr Prescott.
Dr Prescott does not recollect saying he wouldn’t meet with the relatives (of dad). The reason he was not present at any of the meetings that took place is simply because he was not included when the meetings were arranged”

What the family actually asked:
Why will Dr Richard Prescott not meet with the family?
Why does Dr Richard Prescott refuse all correspondence with the family?

So Dr Prescott was not present at any of the meetings because he was not included?
Utter codswallop!

Agreed at March 2015 face to face meeting (in A4 action plan) that Dr Prescott should be present at a meeting to answer questions with the family. At the following meeting in August 2015, the meeting was opened with Dr Kaushik questioning the family about Dr Prescott’s findings at his post-mortem, yet when we asked anything about Dr Prescott, we got “no comment” from the senior staff present. He wasn’t present. Why not?

During discussions with Chief coroner for East Lancashire, Dr Prescott would only converse via the Chief coroner’s office and not with the family.
Perhaps Dr Prescott could explain why the family wasn’t informed of their right to have independent people present at his post-mortem for dad?
Yet another incident of standard practice not being followed.

We arrived at Royal Blackburn’s mortuary for dad’s slides and asked for dad’s FNA slides also, Dr Prescott refused to release them to us. Why?
While there, Dr Prescott refused to come out and sent his assistant instead. Why?

To put it bluntly Kevin… Pull the other one it’s got bells on!

“Did (dad) have a dietetic assessment plan?”

What the family actually asked:
Why were enteral feeding bloods not taken when the dieticians asked for them?
Why were the family being told to feed with snacks, when symptoms were present of diabetes?
Why were ward nurses verbally telling the family that dad was eating well, when nurses notes revealed dad was eating very little?

The dietetic assessment plan is well documented in the ward notes, hence why we did not need to ask about a plan being in place.
Dieticians twice asked for enteral feeding bloods to be done, but they never were. Why not?
Dieticians noted that dad was informed that his stools needed to be observed, using the Bristol stool scale. The Bristol stool scale chart in dad’s medical notes is completely blank, it was not done. Why not?

“When did the patient fall? Did (dad) have a falls risk assessment pre and post fall? If pre, was the assessment outcomes followed?
A simple falls risk screen were completed on 9th September.
A fall was sustained on 21st September at 03.20hrs, when dad was found on the floor after trying to pick something up. The post falls checklist was completed appropriately – with the exception of the family being informed – and lying and standing blood pressure was recorded.”

What the family actually asked:
Why were the family not informed of dad having a fall while on ward C1 of Royal Blackburn hospital?
Why was standing and lying blood pressure not completed on the post falls action plan?
Why did FY1 doctor make false representations in dad’s ward notes, that they witnessed the fall when written evidence shows they did not?
Senior Matron, Nicola Robinson promised to investigate this (March face to face meeting) but come August face to face meeting, had no comment to make about it, why?

We know when dad had a fall, the nurses have recorded it.
Still no explanation of how Royal Blackburn’s FY1 doctor could attend 10 minutes after a fall and witness it at the same time?
Even the nurses on the ward didn’t witness the fall and recorded in dad’s notes that the fall wasn’t witnessed, so how could the FY1 doctor who came along even later, go into such detail about what they had seen/witnessed and how it happened? No reply to that Kevin?
Senior Matron Nicola Robinson promised an investigation to find out what happened and why it was “witnessed” when she agreed it clearly wasn’t, we waiting months and got nothing from her. Why Kevin?
Why not answer what we actually asked?

“When was (dad’s) blood glucose tested, was it 19.6, what did we do to manage the blood glucose and did we pass this information on to the GP?
Ambulance recorded blood glucose at 19.6 on attendance to the emergency dept. (8th September) This should have led to further testing of glucose levels.
(Dad’s) glucose level was 10mmols at 3.40am on 21st September following (dad’s) fall. On checking ICE (pathology database) no further glucose tests were taken.
The glucose level should have uploaded automatically to ICE, this did not happen.
Again, this result should have led to further investigations and monitoring around the higher than normal blood glucose levels. Regretfully, the information was not relayed to the GP on discharge.”

What the family actually asked:
Why was dad’s blood glucose not retested when it was found to be 19.6?
Why was dad’s blood glucose not retested when it was found to be 10 after his fall?
Why was the GP not made aware of dad’s high blood glucose levels?
Why was no treatment offered to dad to help with his diabetic symptoms?

We didn’t ask when dad’s blood glucose was tested as it was documented by the paramedics on their paperwork and passed to the staff at the emergency dept.
Nicola Robinson suggested that “MAU staff don’t get that much time with patients and it must not have been handed on to them, in turn they were unable to pass it on to the ward C1 staff. I will look into this” – it was placed on the A4 action plan at the March 2015 face to face meeting.
By the August 2015 face to face meeting, no investigations had been done, Nicola Robinson told us “I write the policy for diabetes, I can confirm your dad did not have diabetes!”

No explanation from Kevin as to why the standard practice of retesting was not followed on the 8th September and 21st September?
No explanation of why dad’s blood glucose results were not entered into their ICE database (which GPs have access to)?
No explanation of why dad’s GP was not informed?
No explanation of why no treatment was offered, despite obvious diabetic symptoms?
Kevin goes a step further here… he fails to answer his own question!
Kevin claims the question is “what did we do to manage the blood glucose?” – he failed to answer himself!

Royal Blackburn hospital not following standard, best practice?

When Dad was taken to Royal Blackburn hospital A&E unit with a blood rash under the skin of his arms and legs, it was suggested to the family that he was “suffering from neglect”
Using a snapshot of dad’s GP records, his “working diagnosis” was written to be: ?underlying malignancy – appears cachectic (read: muscle wastage/severe weight loss) this was without any test results being returned.

Weight loss:
Royal Blackburn’s staff deemed dad to be suffering from serious weight loss, after comparing his weight on admission to his weight in GP records (this was in September 2014).
Dad’s last GP weight record was from 2005 and clearly documented as such, some 9 years earlier!

SIRS/Sepsis:
SIRS = if 2 or more of 4 criteria are met –
Dad’s presenting symptoms met two of the four criteria for SIRS – The SIRS/Sepsis care bundle was not used.
Sepsis = SIRS + new infection –
Dad presented with a new blood rash to his arms and legs (read: infection).
The SIRS/Sepsis care bundle was not used.
Severe sepsis = sepsis + organ dysf –
Abnormal LFTs (Liver function tests) – Dad’s admission form stated “deranged LFTs”
The SIRS/Sepsis care bundle was not used.

In our March 2015 face to face meeting (recorded), Royal Blackburn’s senior matron, Nicola Robinson claimed, “MAU have only a limited time to assess patients, I’ll look into why the SIRS/Sepsis care bundle was not looked at and also feed it back to the department”
This was placed on the A4 action plan for information to be given to the family – over a year later, we are still waiting!

Blood sugar/glucose – Diabetes?
Paramedics recorded a blood sugar level of 19.6 before taking dad to Royal Blackburn hospital.
Senior matron Nicola Robinson claims (on record) that this will have been retested (as it’s standard practice) and justifies it as being retested after dad had a fall whilst on ward C1.
Dad was admitted and tested by paramedics on 8th September 2014.
Dad was tested for the first time by Royal Blackburn staff after his fall in the early hours, on the 21st September 2014, scoring a blood sugar level of 10, after not eating for over 8 hours.
According to Royal Blackburn’s senior matron Nicola Robinson, “I will look into this and come back to you” (read: A4 action plan – March 2015 face to face meeting)

At our follow up meeting in August 2015, Nicola Robinson said this, “I write the diabetic criteria for Royal Blackburn and I can categorically say that your dad did not have diabetes!”
What about your promised investigation into why dad was not retested?
What about all the diabetic symptoms dad had?
What about the complete lack of treatment dad received for any of these symptoms?
How can Nicola Robinson be fit to make this assumption when Royal Blackburn hospital staff had failed to retest dad?
Who ordered that the standard practice of retesting blood sugars should not be done? (Ward consultant, on ward rounds, talking to ward sister?)
Not a word from Nicola Robinson, senior matron at Royal Blackburn hospital!

It gets worse…

On the 12th and 15th September, while dad was in hospital, the dietician requested “enteral feeding bloods” to be done. They were never done.
Enteral feeding is via a tube into the stomach, as dad was said to be terminally cachexic (muscle wastage) and his MUST score recorded as 5 (showing he needed enteral feeding) this is very disturbing.
What follows is beyond belief.

Dad had most of the symptoms of type 1 diabetes (as listed by diabetes UK).
Dad had a blockage in his pancreas (the insulin producing organ).
Dad never had his high (recorded) blood sugar levels retested in Royal Blackburn hospital (as is standard practice).
Two senior clinical staff (Dr Oliver Nicholson, radiologist at Royal Blackburn and Dr Robin Moseley of Addenbrookes hospital) had both suggested “Chronic pancreatitis”

In April 2016, Kevin McGee (Chairman of East Lancashire Health Trust – ELHT) wrote to our MP Graham Jones. On the subject of dad’s dietician requesting enteral feeding bloods to be done (while dad was in Royal Blackburn hospital) and why they failed to do them.

“On the 12th and 15th September 2014 the dietician requested enteral feeding bloods to be done to help aid nutritional monitoring. Magnesium and Phosphate were not checked, which would have given additional information, although this was not essential to his (dad’s) dietetic treatment.”

I’ve underlined “Magnesium and phosphate were not checked” as this is very significant.
Phosphate has well documented effects on magnesium absorption in the body.
Magnesium is essential for the effectiveness of insulin.
Without magnesium, the pancreas cannot secrete enough insulin, or the insulin it secretes won’t be efficient enough to control blood sugar levels, causing diabetes (as well as vascular problems).

To put it simply, if magnesium and phosphate levels were checked via enteral feeding bloods as requested by RBH’s dieticians, then diabetes (whether temporary or permanent) would have been picked up, recorded and acted upon.
Despite being asked directly by the family, Royal Blackburn and East Lancs Health Trust have offered no explanation as to why standard practice was not followed and the blood tests were not done.

More revelations from Kevin McGee (chairman) of East Lancs Health Trust, when the family asked, “What did Royal Blackburn do to manage dad’s blood glucose and why did Royal Blackburn not pass blood glucose information to dad’s GP?”;

“Ambulance recorded 19.6mmols on attendance to Royal Blackburn hospital’s emergency dept. (8th September 2014)
This should have led to further testing of glucose levels. [It did not]
The glucose level was 10mmols after (dad’s) fall (21st September 2014).
This glucose level should have been uploaded to ICE (Pathology database – which GP has access to) and did not happen.
Again, this result should have led to further investigations and monitoring around the higher than normal blood glucose levels.
Regretfully, the information was not relayed to (dad’s) GP on discharge from hospital.”

So which Royal Blackburn ward consultant (Dr Mansoor?) decided that blood glucose levels did not need testing again while on ward C1, as is best practice?
Why were the blood glucose test results not uploaded to Royal Blackburn’s ICE pathology database? (Used by GP and pathologist at post-mortem)
Why did Royal Blackburn’s senior matron, Nicola Robinson, claim (at our August 2015 face to face meeting – on record) that “your dad’s glucose was retested and within normal limits” when East Lancs Health Trust chairman Kevin McGee now concedes that dad’s blood glucose levels were showing “higher than normal levels”?

The fundamental questions we asked have never been answered by Royal Blackburn’s senior staff or East Lancs Health Trust chairman Kevin McGee;
“Why did Royal Blackburn not pass blood glucose results on to dad’s GP?”
“What did Royal Blackburn do to manage dad’s blood glucose levels?”

Put these revelations altogether and it raises very serious questions for East Lancs Health Trust and Royal Blackburn senior staff to answer.
It is very strange that while having a “working diagnosis” of “possible pancreatic cancer” standard practice blood glucose testing was not done, of the two that were done, none were recorded on to the ICE database (which would have been accessed by dad’s GP to treat his symptoms and Dr Richard Prescott – the self proclaimed “independent” pathologist that despite diagnosing dad with cancer and sitting on Royal Blackburn’s HPB MDT, failed to inform the coroner’s office – when carrying out dad’s post-mortem).
Over a year and a half and still no explanations from Royal Blackburn senior staff or the Chairman of East Lancashire Health Trust, Kevin McGee, into why best practice was not done and whom was responsible for these failings.

Enteral feeding bloods would have revealed diabetes – these were not done despite clinical staff requesting them on the ward.
Retesting of blood glucose levels would have revealed diabetes – these were not done on the ward despite being NICE guidelines and best practice.
Dad’s blood glucose result, taken after a fall in the middle of the night, was not uploaded to Royal Blackburn’s ICE (pathology database) as is standard practice.
None of dad’s blood glucose results were passed on to his GP. (Exactly the same as the results from dad’s cytology biopsy which returned “no evidence of malignancy”)

This all pails into insignificance, when the family had to witness dad having severe symptoms of diabetes and not having them treated from 8th September to 21st October 2014 when he passed away, according to his clinical need (GMC good medical practice, Hippocratic oath, NICE guidelines and East Lancs Health Trust policy).

Dad’s fall while in Royal Blackburn hospital (ward C1):
We have continued to ask why Royal Blackburn’s on call ward doctor, falsified ward records to claim that dad’s fall “was witnessed”.
The on call doctor even added an explanation of what happened despite not being present, as stated by nurses present at the time and Royal Blackburn’s senior matron, Nicola Robinson, in our face to face meeting in March 2015 (on record).

Kevin McGee (Chairman of East Lancs Health Trust) wrote to our MP Graham Jones, with a completely different question and gave an answer to that.
Kevin McGee wrote, “When did (dad) fall? Did he have a falls risk assessment pre and post fall?”
What we actually asked was,
“Why was dad’s standing and lying blood pressure not taken after his fall?
Why was the family never told?
Why did the on call doctor record that the fall was witnessed by them and then proceed to give an explanation of what happened when they were not present at the time?”

Of course, Kevin McGee’s written response fails to answer any of the family’s questions.

Best practice and NICE guidelines have a falls checklist.
It includes various things to be recorded in the event of a patient suffering a fall.

Nurses recorded that dad’s fall was NOT witnessed.
FY1 on call doctor arrived on the ward later to check on another patient and was asked by nurses to check on dad.
The FY1 doctor recorded that dad’s fall WAS witnessed by them. It even explained how it happened and what they had witnessed, completely false and misleading!
Nurses recorded that the family needed to be told of dad’s fall, this was never done.
We didn’t find out about dad’s fall in hospital until months after his death when we finally received some of his medical notes from the hospital.
Dad’s standing and lying blood pressure was to be taken and recorded, this was never done.

Royal Blackburn’s senior matron, Nicola Robinson (at our March 2015 face to face meeting) agreed (on record) that the fall couldn’t have been witnessed and promised to investigate what had been reported by the FY1 doctor at the time (via our A4 action plan).
Nicola Robinson, senior Royal Blackburn staff and East Lancs Health Trust chairman have as yet, failed to answer or address why standard practice was not followed and why dad’s written records were falsified by the FY1 doctor on call.

Royal Blackburn hospital senior staff have not followed best practice and NICE guidelines. Why not?

Royal Blackburn Hospital – lies and deliberately misleading patient’s family

A meeting with senior Royal Blackburn hospital staff and the family, said to have been set up to answer serious questions about their failure to care for dad took place in March 2015.
What followed was a catalogue of lies, false and misleading information, with added fob offs and promises that further information would be provided and investigations made, most of which, never came about.

Present at this meeting:
LD (Business manager – read: complaints – for gastro)
AM (lady who set up the meeting in good faith and made recorded copies of it)
Dr Mansoor (Senior ward consultant for dad, and later promoted to Royal Blackburn’s HPB MDT)
Nicola Robinson (Senior matron at Royal Blackburn hospital)

After small lesion was found during CT scan on dad, Dr Oliver Nicholson (Radiologist at RBH) then investigated further for “staging” (NHS standard practice)
Staging showed “no invasion of coeliac, SMA, splenic vein or portal vein” – he found no evidence.
(Staging of T4 – final stage cancer diagnosis – was made by HPB MDT 2 days later)
“More expert radiologist is present at the HPB MDT, so they look at the scan again and can over-rule it”
FACT: Dr Nicholson was Royal Blackburn’s most senior radiologist at that time and was not qualified to sit on the HPB MDT team, let alone over-rule his own findings.
FACT: Written evidence shows that there was no radiologist present at Royal Blackburn’s HPB MDT meeting when the CT scan findings were over-ruled and final stage T4 diagnosis was made.
FACT: Only qualified HPB MDT staff can over-rule the findings, if none were present whom made this decision? (Mr David Chang – surgeon and HPB MDT clinical lead says he did not over-rule, Dr Kaushik – gastro physician on HPB MDT says he did not over-rule) So who did? Are they qualified to over-rule a radiologist’s findings (Which suggested “chronic pancreatitis”)?
How many more patients are having their diagnosis made by senior Royal Blackburn staff that are not qualified to over-rule medical results?

Dr Mansoor – “We can find out whom was present at each of your father’s HPB MDT meetings”
LD – “It will go down as an action on our (A4 sheet of action) plan”
David Chang (surgeon and HPB MDT clinical lead) and Kevin McGee (Chairman of East Lancs Health Trust) have blocked release of whom was present at Royal Blackburn’s HPB MDT meetings for dad, to both the family and the Information Commissioners Office (ICO).
They claim that “It’s not in the public interest to release the details of which staff were present”
LD was removed from the case around a month after this meeting, she told senior Royal Blackburn staff “But what about the (A4) action plan?”
Senior Royal Blackburn staff told her that we (the family) had now been given the information agreed on the A4 action plan. This is a complete lie, we have not received any of the information listed on the A4 action plan and it’s now a year later!

LD – “The oncologist is there as well (HPB MDT meetings)
FACT: Written evidence shows there was no oncologist present at HPB MDT meeting where final T4 stage cancer was diagnosed.
Kevin McGee (East lancs health trust chairman) cannot decide how many there were present.

In his November 2015 letter to the family… “There were three oncologists present at HPB MDT”
In his April 2016 letter to the ICO… “Oncologists would have been present”
In his April letter to our MP Graham Jones (via the Dept. of Health) he says “There was one oncologist present”
Which is it Kevin?
Kevin won’t name them and has blocked the information from being released without a court order. I wonder why?

Dr Mansoor – “The chances of having a false negative from fine needle aspirate cytology (FNA) are 10% to 20%. So it was a case of a false negative test”
FACT: Kevin McGee (Chairman of East Lancs Health Trust) and senior Royal Blackburn hospital surgeon and clinical lead, David Chang, say different…

Kevin McGee – “The success rate of a first time FNA (cytology) in our unit is 92% to 95%”

Nationally, the accuracy of a negative “no evidence of malignancy” FNA (cytology) test, is close to 98%.
As the “no evidence of malignancy” test results were carried out by Dr Robin Moseley (clinical lead of Addenbrooke’s cancer hospital) we have no reason to believe they were “a false negative” as Royal Blackburn’s HPB MDT and Kevin McGee claim.
When it’s factored in, that all cytology at that time, had to be sent away for testing, as there were no qualified staff to test FNA cytology, in the whole of Lancashire, it raises the serious question of who was sitting on Royal Blackburn’s HPB MDT team, whom thought that they were qualified to over-rule Dr Robin Moseley’s findings of “no evidence of malignancy” and “chronic pancreatitis” findings?

Family – “Right up until dad died, no retesting was ever done, do you find that acceptable?”
Dr Mansoor – “Yes because there are a number of reasons for taking cancer to be the diagnosis”
Family – “The CT scans showed no evidence of invasion (staging of T4 was wrong), the FNA cytology tests returned ‘No evidence of malignancy’ and both stated this was chronic pancreatitis…”

FACT: At the time of discharge from ward C1 under Dr Mansoor’s, there was not one single positive test result for pancreatic cancer.
Dr Mansoor claimed (at meeting with mum and sisters) that a DNR was put in place as dad had “aggressive, spreading staged T4 terminal cancer”
Yet Royal Blackburn senior staff cannot provide one single positive test result to confirm this was the correct diagnosis.
Oncologist did not even look at dad, as they cannot act until there is a positive test result to confirm diagnosis.
MacMillan nursing staff cannot treat until they have a positive test result to confirm diagnosis.
That both of them did not even look at dad, shows that Royal Blackburn HPB MDT staff got their diagnosis wrong. They were not even present at dad’s HPB MDT meetings, as they were not required until a positive test result was presented to confirm diagnosis.

Family – “MacMillan say they had no details on file for dad and could not attend to his needs due to this”
Nicola Robinson (senior matron) – “That’s a breakdown between district nursing and MacMillan, would you like me to look into this?”
Family – “MacMillan say that essential information for dad was not present”
Nicola Robinson pledges to investigate why they didn’t have dad’s “information”
FACT: Nicola Robinson has failed to provide any answers as to why MacMillan (Royal Blackburn hospital’s own specialist palliative care staff) didn’t have dad’s information.
FACT: MacMillan state they cannot administer any “end of life pack drugs” until they have a confirmed positive test result for cancer.
Royal Blackburn hospital couldn’t provide a positive test result as they didn’t have one.
FACT: Kevin McGee has stated in writing that the “specialist palliative care team were NOT in attendance at any of dad’s HPB MDT meetings”
Not only is this a legal requirement under the MDT quorum (and that previous claims by Kevin McGee of their being in attendance was false and misleading, but it also shows negligence on the part of Royal Blackburn hospital senior staff.
A patient suffering from DIAGNOSED stage T4, terminal cancer, doesn’t require specialist palliative care staff to be present at his own HPB MDT meetings where his care pathway is determined?
Outrageous!

Family – “Why did Royal Blackburn hospital staff not pass on the negative cytology results to MacMillan or dad’s GP?”
Dr Mansoor – “I did not have those results!”
Family – “GP contacted you for weeks for those results, nobody gave the GP the “no evidence of malignancy” results until the day before dad died?” (weeks after he left Royal Blackburn hospital)
Dr Mansoor – “nobody contacted me for those results!”

The negative test results Dr Mansoor claims he had never seen.

The negative test results Dr Mansoor claims he had never seen.


FACT:
Dr Mansoor DID receive the negative test results, the email above (released thanks to the ICO) shows clearly he was made aware of the results by the Critical Nurse Specialist (CNS) whom was present at dad’s HPB MDT meetings.
Dr Mansoor took no action and failed to notify dad’s GP or MacMillan nursing team until the day before dad died, almost a month later.
Dr Mansoor sat in front of the family and lied to our faces.

Dr Mansoor was promoted to Royal Blackburn’s HPB MDT team not long after our March 2015 meeting.
Dr Mansoor has not only published false and misleading information to the family (of a patient supposedly in his care), he has also claimed on record, that he had never received negative test results, when later released emails show that he DID receive negative test results and took no action.
Dr Mansoor has yet to say exactly WHY he took no action to help our dad?

East Lancashire Coroner’s office

A coroner’s office should be beyond reproach.
A trusted source of information, offering a service to the public at one of the worst times in their life.
They deal with bereaved families, it’s a vital role, legal safeguards are in place to protect not only the coroner’s service, but those whom are bereaved.

So perhaps East Lancashire Coroner’s office, would like to answer the following questions?

  • Why did the Chief Coroner of East Lancashire ignore written evidence and negative test results, then instead chose to believe the word of the pathologist from Royal Blackburn Hospital (Dr Richard Prescott), whom did not declare that he not only had professional colleagues (Mr David Chang) whom had diagnosed dad, but also sat on the very same HPB MDT and played a part in the diagnosis made by Royal Blackburn hospital?
  • Why did the Chief Coroner of East Lancashire refuse the family an inquest, then admit that the findings of his own pathologist (Dr Richard Prescott) review of the negative test results, couldn’t be used to make a decision about an inquest, as he was not a practising cytopathologist?
  • Once revealed by the pathologist (Dr Richard Prescott) that cause of death was Bronchopneumonia (bacterial infection), why did Mr Richard Taylor (Chief Coroner for East Lancashire) then give Dr Prescott permission to take extend the time for his report and take samples from dad’s pancreas and have them tested? (the final opportunity to justify his own diagnosis, from when he sat on Royal Blackburn’s HPB MDT meetings)
  • Why did Richard Taylor, East Lancs Chief Coroner, refuse to give any opinion, when it was revealed to him by the family that Dr Richard Prescott had not only not declared any conflict of interest (in carrying out the post-mortem), but also made representations to the Deputy Coroner (whom has his office at Royal Blackburn hospital) that he was, “completely independent from the living side of the hospital” – when Dr Prescott knew all along that this claim was false and misleading?
  • Why would Mr Richard Taylor tell the family, “If you are not happy with the post-mortem, I suggest you take it up with the hospital”?
  • Why would the Chief Coroner’s office ignore the family’s requests to release a copy of dad’s full file?

The East Lancashire Chief Coroner’s office have dad’s file, it took barely a week to get it back to their office from the archives (as confirmed by Richard Taylor’s secretary).
“I will have to ask Mr Taylor before it can be released, but it shouldn’t be a problem, he’s on leave until next week.”

Fair enough, but three weeks later, no file, no release, East Lancashire Chief Coroner’s office are ignoring all phone calls or emails from the family and the mysterious dad’s file that they have in their office, is nowhere to be seen. Why?
Not a single effort to explain what’s going on to the family.

Under General Medical Council (GMC) rules, any possible conflict of interest MUST be declared, BEFORE a pathologist carries out a post-mortem for a coroner.
With any conflict of interest the Chief Coroner (Richard Taylor) makes the decision.
Dr Richard Prescott (pathologist at Royal Blackburn Hospital) declared he was “completely independent from the living side of the hospital” despite knowing that he made the diagnosis and was directly involved in the care pathway (or lack of) for dad, alongside Mr David Chang (clinical lead of Royal Blackburn’s HPB MDT).

If there is bigger conflict of interest than this, what could it be?
Why exactly did Richard Taylor, East Lancashire Chief Coroner, decide that Dr Richard Prescott (Royal Blackburn hospital’s pathologist) was fit to carry out dad’s post-mortem (having no conflict of interest), ignoring representations from the police, the family and dad’s GP?

Multi Disciplinary Team (MDT) vanishing?

Royal Blackburn hospital’s HPB MDT team are a magical entity, that changes more often than the weather (sarcasm mode on).

Dad had three HPB MDT meetings to assess his care/treatment, two while he was in Royal Blackburn (ward C1), one after he was discharged.
Every aspect of these meetings has changed according to every member of senior Royal Blackburn’s senior staff and East Lancs Health Trust chairman Kevin McGee.
The Care Quality Commission (CQC) and the General Medical Council (GMC) have been offered written and recorded evidence of failings, but do not want to see or consider it.

HPB MDT meeting 1:
This took place on September 12th 2014.
Hospital notes show that nothing was discussed and notes returned to the ward not filled in (Mr David Chang, clinical lead of HPB MDT meetings is on record claiming “all meetings are recorded live” and it is required for the MDT meeting to be deemed quorate)
Nurses recorded that the outcome of this MDT meeting “needs to be chased up”.

Senior surgeon and clinical lead Mr David Chang claims “this meeting simply never took place, so there is nothing to discuss” – Written evidence shows Mr David Chang is telling the family lies, deliberately misleading and publishing false information.

HPB MDT meeting notes from the following week (19th September 2014) shows clearly that the diagnosis of terminal T4 stage cancer was made at the 12th September 2014 HPB MDT meeting.
These notes also show that an EUS FNA (cytology biopsy) was to be taken from dad and sent away for testing to confirm this diagnosis.
MDT update notes from the ward also show that various staff also knew about the “care plan” decided at the 12th September HPB MDT meeting (that Mr David Chang claims “never took place”) – Dieticians, ward consultant Dr Mansoor, ward doctors, nurses all recorded that an EUS FNA was to be done, all before Mr David Chang claimed it was decided at the 19th September HPB MDT.
The final damning evidence against Mr Chang’s claims, is that the doctor carrying out the procedure, Dr Kaushik, sits on the same HPB MDT team. He has confirmed on record that he was present at all three of dad’s HPB MDT meetings.
Written evidence shows that the EUS FNA procedure was carried out on the 18th September 2014… 24 hours BEFORE it was decided to be done at the 19th September HPB MDT meeting!

If Mr David Chang is to be taken seriously with his claims, then surely Dr Kaushik, sitting next to him at the 19th September HPB MDT meeting, would have informed Mr Chang that he had already carried out the procedure on the 18th September?
The notes from that meeting show that he did not. We have a copy of the email sent by the Critical Nurse Specialist (CNS) on the 22nd of September, advising Dr Mansoor (ward consultant) that dad would need an EUS FNA done.
Both Dr Kaushik and the CNS have stated on record that they were present at the 19th September HPB MDT meeting, so how/why did they know it had already been done?

East Lancashire health Trust chairman Kevin McGee confirmed in writing in November 2015 (yes, a full year to establish that an HPB MDT meeting DID take place) that the meeting of the 12th September DID take place, but dad “wasn’t discussed at this meeting as all the information/tests/results weren’t available” – more false and misleading information from Mr David Chang, as the same information/tests/results weren’t available for the 19th September HPB MDT meeting either!
In fact there are no notes from the 19th September HPB MDT meeting, all that is recorded is on these notes is what was discussed at the 12th September HPB MDT meeting, written evidence confirms this is accurate, despite Mr David Chang’s claims.

So why, despite overwhelming written evidence, does Mr David Chang continue to publish false and misleading information about the 12th September HPB MDT meeting not taking place for dad?

Could it be that the meeting did not meet the MDT quorum?

East Lancashire Health Trust chairman Kevin McGee and Mr David Chang have blocked the attendance records of the HPB MDT meetings from being released to the family.
Care Quality Commission, that should have access to the HPB MDT attendance records when inspecting hospitals, refuse to confirm or deny if these were provided when they inspected Royal Blackburn hospital.

The 12th September 2014 HPB MDT meeting at Royal Blackburn hospital did not meet the MDT quorum – we have written evidence of this.

That it did not meet the quorum is not irregular, that a diagnosis was made on dad and claims that his CT scans (showing pancreatitis) were over-ruled by more “expert” MDT senior staff, is highly irregular.
For a non quorate MDT meeting to over-rule test findings is very serious.
An MDT expert can over-rule, but if the meeting does not have the senior “expert” present then no decision is to be taken, it has to be referred higher up the expert chain, to a medical professional in that field more specialised.

Dad’s CT scans showed a small blockage at the head of the pancreas, as the radiologist Dr Oliver Nicholson is a very competent radiologist, he then examined further to establish if the blockage was invasive.
Dr Nicholson found “No invasion of the portal vein, splenic vein, SMA or coeliac” Dr Nicholson suggested it could be pancreatitis.

Mr David Chang and Dr Mansoor (ward consultant) have both claimed on record, that these findings were “over-ruled at MDT level by a more senior expert radiologist”
This is why we have asked numerous times to see the attendance records of whom this radiologist was, sitting at MDT level.
At the time, Dr Oliver Nicholson was Royal Blackburn hospital’s most senior radiologist, he was not qualified to sit on the HPB MDT team.
IF (and it’s a huge IF) he was called in to the MDT to give his opinion, are we seriously to believe that he over-ruled his own findings?

Written evidence provided by Royal Blackburn’s own senior staff, shows that no radiologist was present at the 12 September HPB MDT meeting.
Mr David Chang and Dr Mansoor (ward consultant) have both been making false and misleading claims, that more “expert radiologist over-ruled these findings at MDT level”
It is a serious issue that needs to be addressed, as dad’s diagnosis, that shaped his care pathway, was decided at this HPB MDT meeting.

East Lancashire Health Trust chairman Kevin McGee’s ever changing account of staff present at Royal Blackburn hospital’s HPB MDT meeting:

I can’t work out which is more inept.
That East Lancs Health Trust chairman Kevin McGee and RBH clinical lead surgeon Mr David Chang keep changing their account and numbers of “expert” staff present at the same HPB MDT meetings (publishing false and misleading information) OR that ELHT chairman Kevin McGee and Mr David Chang can’t see any issues of patient safety being affected by running HPB MDT meetings on care pathways and diagnosing patients, without the correct quorum of “expert” qualified staff being present?

Either way it does not look good, nor is it acceptable under any circumstances.
Who are these mysterious “more expert” MDT staff whom are over-ruling qualified test/scan results?
Are they qualified to over-rule?
What if they are wrong when they over-rule?
This could lead to misdiagnosis, wrong care pathways and treatments, dangerous to the patient when drugs administered come into play. It’s nightmare waiting to happen.
On the other side of this, is if the top brass are deliberately blocking release of essential information, where is the accountability?
How many more patients has/is this happening to?

I’ll end this post with something to reflect upon.
East Lancs Health Trust chairman Kevin McGee has now put in writing several different accounts of the professions that were in attendance at Royal Blackburn’s HPB MDT meetings for dad.
In November 2015 Kevin McGee wrote to the family stating,

“In attendance at the HPB MDT meetings were two consultant surgeons, one consultant gastroenterologist, two consultant radiologists, one consultant histopathologist, three consultant oncologists, an upper gastro-intestinal tract clinical nurse specialist and a MDT co-ordinator”

That’s eleven essential “expert” MDT core members.

In reply to the Information Commissioner’s Office ruling against them, East Lancashire Health Trust’s account had changed to (at least) eighteen “expert” MDT staff,

“We are able to advise that the following classes of staff would have attended each of the meetings :

  • Consultant surgeons
  • Consultant physicians
  • Consultant radiologists
  • Consultant histopathologists
  • Consultant cytopathologists
  • Consultant oncologists
  • Specialist nurses
  • Research nurses
  • Dieticians and administrative staff”

In reply to our MP Graham Jones and the junior Health Minister at the Dept. of Health, East Lancs Health Trust chairman Kevin McGee wrote,

“All three HPB MDT meetings had in attendance the following essential members;

  • A consultant surgeon
  • A consultant GI physician
  • A consultant radiologist
  • A consultant histopathologist
  • An upper GI nurse specialist
  • A consultant oncologist

The specialist palliative care team (read: MacMillan nurses) were not in attendance.”

There was only ever one consultant surgeon present – Mr David Chang (Reply 1 and 2 state minimum of 2 consultant surgeons – false)
There was only ever one upper GI physician present – Dr Kaushik (Reply 2 states there were more one present – false)
Radiologists present – Reply 1 and 2 claim more than one were present, reply 3 claims just one was present (written evidence shows that NO radiologists were present – false)
Histopathologist present – Reply 1 claims just one present, reply 2 claims more than one were present (even though only one sits on the HPB MDT) reply 3 claims there was just one present (written evidence shows that NO histopathologist was present at the first HPB MDT meeting where diagnosis was made and results were over-ruled – false)
Oncologists present – Reply 1 and 2 claims there were three oncologists present, reply 3 claims only one oncologist was present (written evidence shows NO oncologist was present – false)
Upper GI Nurse was present – Reply 2 claims “specialist nurses” there was just one (written evidence shows that just one upper GI nurse was present, but copies of emails show that the nurse who “was present” did not know that the EUS FNA had already been done, even though she was at the MDT meeting with the upper GI physician whom carried out the procedure), very odd.
Specialist palliative care nurses (read: MacMillan) – Reply 1, no specialist nurses were present, reply 2 specialist nurses were present, reply 3 it’s changed again to the specialist nurses not being present (even though this is a requirement of the MDT quorum!)
Research nurses – There was never any attendance by research nurses, we have no idea where this comes from in reply 2 – false information again.
Dieticians – again, no idea where reply 2 answer comes from, they simply were not in attendance at any of the MDT meetings and are not a core member of the MDT.
MDT co-ordinator/administrative staff – MDT co-ordinators have to be present and record events in real time. Written evidence shows they were not present at the 12th September MDT meeting, despite claims in reply 1 and 2 that they were present, in reply 3 reference to them being present has disappeared.

It’s hard not to conclude from the fabrications, false and misleading information coming from East Lancs Health Trust chairman Kevin McGee via Royal Blackburn hospital senior staff, that they have not one clue about what they are doing!
Publishing false and misleading information – whether by accident or knowingly – by any senior management of a public body, is a criminal offence!

Post-mortem process is corrupt…

Coroner calls for a post-mortem, pathologist carries out post-mortem, reports to Coroner on cause of death, Coroner looks at whether an inquest is needed, or accepts findings and holds no inquest, body is released for burial.
Pretty straight forward process in most cases.

The family are legally entitled to request an independent pathologist – one not connected in anyway, professionally, with the hospital concerned if it was involved in the care of the patient.

Our family requested this when the police officer visited the family home.
The police officer agreed and informed the East Lancs Deputy Coroner (Martin Hall) who’s office is at Royal Blackburn Hospital (RBH).
Within an hour, Martin Hall phoned the family home (in rather a heated exchange) insisting that RBH’s senior Pathologist, Dr Richard Prescott was “completely independent from the living side of the hospital” and that he would be carrying out the post-mortem.

The family didn’t want this.
In light of dad leaving hospital with a terminal cancer diagnosis, having a biopsy (cytology) done in September 2014 and the family/GP/MacMillan nursing staff were not informed of the “no evidence of malignancy” (and the need for a retest) results from the 26th September 2014 until the 21st October 2014, just one day prior to dad passing away. Trust in Royal Blackburn Hospital senior staff was very low.

Martin Hall, the deputy coroner for East Lancashire continued to proclaim his independence.
The post-mortem went ahead.
When the findings came back, after a delay said by Martin Hall to be, “due to waiting for histopathological biopsy tests” the cause of death was said to be 1a. Bronchopneumonia 1b. Pancreatic adenocarcinoma.
This immediately raised our suspicions as Bronchopneumonia is a serious bacterial infection, not related to cancer.
We asked to see the histopathology test results. Martin Hall didn’t produce them.
We asked the East Lancs Chief Coroner Richard Taylor for a review of these test results, which he kindly asked RBH’s histopathologist (Dr Richard Prescott) for.

Once again the review took some time, when it came back, Dr Prescott had just four lines to say about the samples he had taken/findings he declared in the post-mortem and samples he had sent away for testing (according to Martin Hall, deputy coroner) instead, Dr Prescott proceeded to attempt to discredit the “no evidence of malignancy” findings of the cytology biopsy taken from dad when he was in ward C1 at Royal Blackburn hospital.
Dr Prescott and Martin Hall both made attempts to claim that the cytology samples tested when our dad was alive, was to put it bluntly “a false negative as in effect, they are taken from a moving target” – we were astounded by this, not because of the terminology, we understood this, but by the identical claims of two independent and separate people involved in the process!
What they both failed to tell the family and the Chief Coroner was that when the cytology samples are taken, an ultrasound camera is used, which is considered to be highly accurate.
A negative cytology result is around 95% accurate, whereas a positive test result only has to be between 50% and 70% accurate to prove a diagnosis.
Dad’s test results came back showing “no evidence of malignancy”.

The Multi Disciplinary Team (HPB MDT) at RBH had ruled this a false negative also.

We dismissed this and asked for a further review from the Chief Coroner for East Lancs. He set this in motion.
Senior RBH pathologist Dr Prescott, once again mostly ignored his own post-mortem test results and instead analysed the cytology samples that returned negative, then changed his opinion.
After claiming in his first view of the cytology samples taken when dad was alive, that these were taken from a “moving target” he now claimed that he “had reviewed the same cytology samples and found there to be definite atypical cancer cells present, albeit in small amounts” – Dr Richard Prescott was now implying that the original findings reported from the cytology samples, were wrong.

The findings did not indicate any cancerous cells were present, according to common practice cytopathology reporting standards, the order of reporting is;

  • No evidence of malignancy
  • atypical cancer cells (cells that could turn into cancer cells in the future)
  • Definitive cancer cells present

We looked into the Cytopathologist whom originally found no evidence of malignancy, a Dr Robin Moseley, who is a clinical lead cytopathologist of Addenbrooke’s cancer hospital. A more expert Doctor we could not have found.

The Chief Coroner then closed down the inquest, refusing one, stating he was satisfied with the expert medical opinion given by Dr Richard Prescott and stated he must rely on this.
When we revealed to the Chief Coroner that we had discovered that Dr Richard Prescott sits alongside one Mr David Chang on the NSSG cancer network, whom is the clinical lead of Royal Blackburn hospital’s HPB MDT team, the very same HPB MDT team that diagnosed dad’s cancer and with held the “no evidence of malignancy” test results from MacMillan (read: Royal Blackburn’s specialist palliative cancer care team), dad’s GP and the family for weeks, the Chief Coroner simply dismissed it out of hand as having no relevance!

With no inquest to take place, it was only now that Dr Richard Prescott of Royal Blackburn hospital revealed to the Chief Coroner that he was not a qualified/practising cytopathologist and a second opinion should be sought.
Which begs the question, why was Dr Prescott giving the Chief Coroner his opinions (as fact) on the “no evidence of malignancy findings” and attempting to discredit them, when he was not qualified to do so?

Legally, Dr Prescott is duty bound to report any possible conflicts of interest to the Chief Coroner when asked to perform a post-mortem. Dr Prescott did not declare any possible conflict of interest, he went further in making representations via the deputy coroner, Martin Hall, that he was “completely independent from the living side of the hospital” – not a single mention that he sits on the NSSG cancer network alongside Mr David Chang, whom is also the clinical on Royal Blackburn’s HPB MDT team, the same expert team that diagnosed terminal stage T4 cancer in dad.

Despite numerous requests and assurances, over several weeks, that we could have a copy of the post-mortem biopsy test results from Martin Hall, East Lancs deputy coroner, we never received them.
The Chief Coroner admitted that he had never seen them either, but claimed it was not something he would be given unless requested.
That we have never received these test results, is no surprise, as Martin hall, deputy coroner let slip in a very heated exchange after the inquest had been refused, that the test results do not exist!
The confirmation of cancer being present in the post-mortem biopsy samples, was the opinion of just one person, the pathologist who carried out the post-mortem at Royal Blackburn hospital, one Dr Richard Prescott!
He doesn’t even have them tested, he simply looks at the slides through a microscope and gives his “expert” opinion.

So why did East Lancashire deputy coroner Martin Hall continue to claim the reason for the delays in Dr Prescott’s findings were due to him “awaiting the return of the post-mortem biopsy results”?
Why did Martin Hall continue to promise the family a copy of the post-mortem biopsy test results if they never existed?
Does Martin Hall (by all accounts an experienced deputy coroner) not know the basic procedure regarding post-mortem biopsy testing?

Benefit of the doubt many readers will no doubt give, fair point I would say. But please consider this.

Over a year after dad passed away, East Lancashire Hospitals Health Trust chairman, Kevin McGee, finally admitted in writing, that Dr Richard Prescott, the “independent pathologist”, whom carried out the post-mortem, is the very same Dr Richard Prescott that sits on the weekly HPB MDT meetings at Royal Blackburn hospital, under the clinical lead of Mr David Chang (sits with Dr Prescott on the NSSG cancer network) and was a member of the very same HPB MDT team, that diagnosed dad with terminal stage T4 cancer!
The same HPB MDT team that sat on dad’s negative test results and did not retest him or pass on the results to dad’s family, MacMillan nursing staff or GP.

Dr Prescott did not declare this clear conflict of interest to the East Lancs Chief Coroner and when we raised concerns about his independence, we were ignored.
The Chief Coroner ended the process by stating that if we had any issues with the post-mortem, we should take these up with Royal Blackburn Hospital.

More serious concerns are raised since we discovered that Dr Prescott had established cause of death (his main role as a pathologist) as Bronchopneumonia, then requested more time and permission to take samples of the pancreas from the Chief Coroner of East Lancashire.
This request was granted.
We cannot see what representations were made for this request, as the Chief Coroner’s office are currently blocking the family access to dad’s file that they hold.

The General Medical Council (GMC) can see nothing untoward in this process, despite it being against their own Good Medical Practice regulations, but that is for another post dedicated to their organisation…

Where to begin?

In forthcoming posts, there will be issues that make uncomfortable reading, some may stir painful memories for you the reader, every thing is painful to our family.
Some issues may ring true with other families’ experiences.
Some readers may chose to comment, some may offer advice, etc.
All are welcomed.

All people named in this place, will be named on the basis of evidence. Not one accusation made will be without foundation and most can be backed up by written and/or recorded evidence.

This website is not here to attack on the NHS. I have no doubt that many staff within it’s employment, in all it’s forms are completely honourable and carry out their work with the upmost diligence and care.
In our experience, there are two types of NHS staff.
Those on the frontline, the nurses and the GPs that the public most associate with the service.
Then we have those holding senior positions within Health Trusts and the consultants that make the decisions that can lead to life or death.

All staff, in what ever role, need to be accountable. It’s as simple as that.
Before a negligence case can be put to a court, frontline staff have to be shown to have been negligent. This is wrong. It does nothing to support those whom we all see on our visits to hospitals and GP surgeries. It merely provides another level of cover for those instructing them.
A nurse may well not take a blood glucose sample (as is standard practise) if those above have diagnosed a different medical condition exists, then the nurses are instructed or not told to, test the blood glucose.

This doesn’t make the nurse negligent in the eyes of the law, so protects those higher up whom are pulling the strings and making the calls.
I hope that makes sense?