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,
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!