Speaking in the Commons today, Health Secretary Jeremy Hunt revealed that, since 2009, 450,000 women in their late 60s had failed to get an invitation to attend a final routine breast cancer screening. He announced an independent review and apologised to the women and their families.
Undetected for nearly a decade until a recent IT upgrade, NHS statistical projections quoted by Mr Hunt suggest that this computer algorithm failure may have directly resulted in the deaths of as many as 207 women. Of the women affected, 150,000 have since died. How many of those deaths were due to other illnesses or simply old age and how many from undiagnosed breast cancer is unclear.
Kashmir Uppal, an Shoosmiths partner who ran the Paterson cases comments:
‘Relatives will be deeply upset to know that their loved one did not receive an invitation for screening at the correct time and as a consequence they may have needlessly died or missed the opportunity for an earlier diagnosis and treatment because of administrative incompetence.’
Even when clinical problems are identified, similar administrative errors or oversights have meant many patients who may have been harmed have been missed in patient recalls or not diagnosed in time.
The firm’s experience in dealing with patients treated by convicted breast surgeon Ian Paterson also illustrated that the patient recall process - which relies on sound administrative practice to be effective - was flawed in both the private and NHS sector.
Mr Hunt stated that all the women affected will now be contacted by letter by the end of May 2018 and those under 75 will be offered a routine catch-up mammogram. A helpline will be set up to assist women aged over 75 by discussing the pros and cons of having breast screening because the likelihood of being diagnosed with breast cancer increases with age.
Kashmir believes this episode illustrates the vital importance to patient safety of simple administrative issues such as ensuring patient records are accurate and up to date and the need for an improved and demonstrably more robust system of monitoring the breast screening process. She concludes:
‘Most instances of patient harm leading to a compensation claim seldom involve a single clinical or surgical error. Instead, they are most often the result of a cascade of missed opportunities. These errors can frequently begin with, or at least be compounded by, something as simple as an IT problem or clerical error.’