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!”
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?
