A Birmingham health authority last night announced that no disciplinary action would be taken against any doctor or hospital manager implicated in the misdiagnosis and mistreatment of 79 patients at one of the country's leading bone cancer centres.
Two of the patients underwent unnecessary amputations, and 13 others suffered "serious and long-term problems" as a result of unnecessary or incomplete radiotherapy and chemotherapy. The death of one other patient may have been linked to misdiagnosis. A total of 53 patients are currently seeking compensation from the South Birmingham Health Authority which is expected to run into millions of pounds.
An independent inquiry report into the errors which occurred between 1985 and 1993 blames Dr Carol Starkie, a consultant pathologist for "unacceptably high level of misdiagnoses in the Bone Tumour Centre at Birmingham's Royal Orthopaedic hospital".
But the inquiry's findings also single out the surgeons who worked with her for failing to alert anyone to the misdiagnoses which were occurring as early as 1989. "In 1990, the surgeons gathered cases where problems in diagnosis had occurred. Even so they apparently failed to recognise the seriousness or level of misdiagnosis until early 1993," the report says. It suggests that they failed to take action because they feared financial cuts.
Hospital managers are criticised for ignoring the concerns raised by surgeons about Dr Starkie's work in numerous informal conversations, and for inadequacies in key policies and procedures which contributed to a disastrous failure of communication at the centre.
Bryan Stoten, chairman of the SBHA said yesterday that he accepted the report's conclusions, and the authority was "fully accountable". However, no disciplinary actions were pending nor would any cases be referred to the General Medical Council on the grounds of professional misconduct. "Most of the actors who were party to these events since 1985 have moved on," Mr Stoten said.
Dr Starkie, 57, who had suffered from multiple sclerosis for many years, took early retirement shortly after the first misdiagnosis of a malignant tumour in a young boy came to light in May 1993. The tumour was benign.
Mr Stoten said the SBHA accepted negligence in 15 of the legal actions it faced, and there had been four interim payments so far and one final settlement.
The findings of the two-year inquiry, chaired by Dr Archie Malcolm, director of the North-East Bone Tumour Registry, is a damning indictment of mismanagement and poor communication which compounded the errors made by Dr Starkie. "Some of the errors that were made would be unacceptable for a non-expert pathologist," the report says.
A spokesman for the Royal Orthopaedic hospital said it had reservations about some aspects of the report but still "deeply regretted" the distress caused to patients and relatives in the last eight years.
"We have learned from the past and have changed our management and clinical practices accordingly.
"We believe this ensures the diagnosis we now employ represent the very best practice available today."Reuse content