RBH – Just a promise

Royal Blackburn hospital’s magical changing MDT attendance records

It is a legal requirement for an hospital (such as Royal Blackburn) to hold and maintain actual attendance records for each and every one of their Multi disciplinary team (MDT) meetings.

We have been attempting to get a copy of three such meetings that took place, in our dad’s case.
Royal Blackburn hospital’s HPB MDT chairman (Mr David Chang – lead cancer surgeon for Royal Blackburn and NSSG north west England cancer team chairman) has blocked each and every attempt we have made to obtain a copy.
Kevin McGee (CEO of East Lancashire Hospital NHS Trust) on the direction of David Chang, has also blocked every attempt made to provide us with a copy of these attendance records.

Senior Royal Blackburn hospital complaint staff have claimed they, “Didn’t know that actual HPB MDT attendance records exist, but we’ll try and get them for you” – then failed to respond ever again.

We have tried to get a copy through our MP Graham Jones and he has written to the Department of Health, again without success.

We have made Freedom of Information requests, where the Information Commissioner’s Office (ICO) have requested copies, they too have been blocked.

We have tried to obtain the copies through the medical records office at Burnley General Hospital, where we were told, “They [HPB MDT attendance records] do exist and we can put in a request for them, but to date, Royal Blackburn hospital senior staff have never released them, in any case!”

So we changed tack, perhaps if Royal Blackburn hospital will not release them to our family, then the Care Quality Commission (CQC) could confirm if they had followed their strict protocols and had the attendance records presented to them when they carried out two hospital inspections at Royal Blackburn hospital (as is required by law)?
They refused to confirm or deny this.
Perhaps the CQC could view the HPB MDT attendance records for the meetings concerning dad on our behalf and confirm/deny that the reported staff to us, were actually in attendance, as we have written evidence of whom was and was not present and the written accounts of David Chang and Kevin McGee were conflicting, to three different official bodies?
After months of deliberation, they passed all our complaint information to them (without permission) straight to… Kevin McGee (CEO of East Lancs NHS trust) and then refused to confirm or deny that they had access to the HPB MDT attendance records.

East Lancashire “Patient voices group” were informed after asking to look over the aspects of our complaint, they did not respond to the family, they instead handed over the details to Kevin McGee and then blocked my account on twitter!

After over a year of asking, senior Royal Blackburn hospital information office staff responded by informing the family that they were refusing to release the HPB MDT attendance records, due to,

“Processing is unwarranted by reason of prejudice to the rights and freedoms or legitimate interests of the individuals who would be identified.
The Trust has considered whether disclosure of the information would be fair”

Fair to whom?
All the family are asking is for copies of the attendance records of senior staff that diagnosed dad’s condition.
It is not relevant whom WAS at the HPB MDT meetings, but whom WAS NOT present at the meetings.

Kevin McGee and David Chang have made three reports of which professions were represented at dad’s HPB MDT meetings, every single one of them has been different and does not tally. (They cannot even agree on when the meetings took place for dad!)
Is this not in the public interest to know that East Lancs Health Trust chairman Kevin McGee and Royal Blackburn hospital’s HPB MDT chairman David Chang (and NSSG cancer network chairman) are making false and misleading statements to members of the public (which is a criminal offence)?

Are the CQC not concerned that each account by staff at the very top of East Lancs NHS trust conflicts?
Does the ICO not see anything wrong with their conflicting accounts?
Why does no official body want to see the evidence?
Why do Lancashire police not want to pursue the case when a crime is reported?

Why are Royal Blackburn hospital and East Lancs NHS trust going to such lengths to block the release of the HPB MDT attendance records if they have nothing to hide?

It is in the public interest to find out that Royal Blackburn’s MDT teams are understaffed.
It is in the public interest to know that Royal Blackburn’s MDT teams have unqualified staff, deciding diagnosis’ on patients, without the clinical knowledge/experience they require to have by law.

Publishing HPB MDT attendance records to a patient’s family may not be seen as ideal to those at the top, but as regards duty of candour, they are legally required to be open, honest and show integrity.
In dad’s case, they have failed on all accounts.

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.

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?

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…