Four years later, it was well-known on the medical grapevine, locally and nationally, that the pathology service run by Dr Starkie was 'second-rate', according to the evidence submitted by surgeons at the Royal Orthopaedic Hospital to the independent inquiry that reported yesterday.
In their report, leaked yesterday to the media, they suggest they were getting nowhere with their complaints about the 'significant difficulties' they were having in getting correct and early diagnoses from Dr Starkie.
With the support of the South Birmingham health authority, the bone cancer surgeons put in a bid to the Department of Health for it to fund the appointment of a new and 'fully committed pathologist'. In March this year, the department turned down the bid saying this was 'an issue for local management to resolve'.
On 20 May this year, four days before the blunders first came to light, Robert Grimer, one of the surgeons, met Dr Gillian Todd, the chief executive of South Birmingham acute services. He told her of the 'increasingly embarrassing situation' that Dr Starkie's perceived failures were causing. The surgeons' evidence continued: 'Dr Todd put her hands over her ears and said: 'I don't want to hear any more. I know all about your problems with bone tumour pathology and I am dealing with it'.'
According to the surgeons' evidence, Dr Todd had first been made aware of the 'indifferent' pathology service Dr Starkie was providing two years earlier. Dr Todd had then pointed out that one of the problems was that Dr Starkie's post was funded partly by the NHS, and partly by the University of Birmingham.
But the surgeons were already taking matters into their own hands. They were regularly requesting second opinions on Dr Starkie's diagnoses from Robin Reid, senior lecturer in pathology at the University of Glasgow and a leading authority on bone tumour pathology.
They felt they received a much more reliable service from Dr Reid. Tests tended to come back more quickly from Glasgow than from Dr Starkie, who was based just two miles away from the orthopaedic centre.
The interim report of the Government-commissioned inquiry, chaired by Archie Malcolm, consultant pathologist at the Royal Victoria Infirmary, Newcastle, showed the bone tumour pathology service at Selly Oak was a shambles, and that there were no systems for rectifying the problem.
It suggested the service was dogged by protracted in-fighting between medical and other health service professionals, and a deliberate closing of ranks by doctors to marginalise management. It seemed that a 'dogmatic and sometimes confrontational approach' by the pathologist in question prevented proper discussion with the surgeons who sent her samples. 'There was also resistance by the pathologist to sending material for a second pathology opinion.'
The inquiry reported that although the surgeons had, over the past three years, many undocumented conversations with managers and colleagues about the poor pathology service, there was no evidence they raised questions about accuracy. They were too afraid of disclosing their concerns in case managers left them with no pathology service at all - which was the last thing they wanted.
The management structure of the bone tumour service at the Royal Orthopaedic was also ill-defined. 'Since 1990 it is unclear as to who officially took the lead role in management. The surgeons dealt directly with the Department of Health, without involving senior managers. The inquiry identified recent fragile relationships and poor communication between senior management and the consultant staff in the bone tumour unit.'
Clinicians were unaware of complaints procedures in relation to the work of medical colleagues. There was no guidance about the reporting of suspicious incidents, or advice about appropriate investigative action.
Perhaps the most damning revelation in the report concerned the cavalier attitude of surgical staff towards patients at the sharp end of Dr Starkie's misdiagnoses. 'The surgeons were aware of a significant number of patients who had been misdiagnosed as early as May 1992, but did not think the service was dangerous. They suggested that South Birmingham had over-reacted by calling an inquiry, and that problems could be dealt with by talking to patients and relatives, as had happened in the past.'
While the inquiry applauded the innovative operative procedures pioneered by the bone tumour unit at the Royal Orthopaedic, citing its 'well- deserved international reputation', its surgeons may have become blinkered to several aspects of patient care and safety, the report states.
Poor communication between the management and the unit, and the professional isolation of the doctors from other health staff, also contributed to the catalogue of failures that snowballed into a scandal.
Dr Starkie was responsible for an 'unacceptably high level of misdiagnoses', the report states. The inquiry was unable to establish whether her physical health - she suffered from multiple sclerosis - contributed to her record of blunders.
Leading article, page 27