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Women had breasts removed in error
By Celia Hall, Medical Editor






 Royal College of Pathologists


 UK Breast Cancer Awareness Campaign


 Cancer Research Campaign


 Department of Health




  TWO women had breasts removed unnecessarily because a pathologist wrongly
indicated that they had cancer.
The hospital trust involved has now ordered an internal investigation of
breast biopsies from women attending Kent & Canterbury and Margate hospitals
between 1990 and 1997. These were carried out by one histopathologist who has
not been named and is no longer working in the area. A "few hundred" breast
biopsies are to be reviewed, a spokesman said.

One of the women who underwent the needless mastectomy has been informed by
the hospital. The second woman is believed to be living abroad. Both women
were wrongly diagnosed in 1990.

The errors came to light in an investigation by the Royal College of
Pathologists, which was requested because of earlier problems with cervical
screening results at Kent & Canterbury Hospital before 1995. Then, eight
women died and 30 needed surgery for cancer.

The histopatholoy audit was recommended by the external inquiry team called
on to investigate the cervical cytology service in 1997. The latest
investigation did not include any cervical smear tests. The pathologists'
report is based on 2,621 samples of tissue sent for laboratory testing for a
range of different diseases, including cancers. The analysis found serious
errors in diagnosis in seven that would "definitely" have an effect on the
patient's condition.

In another 35 cases it was found that the discrepancies would "potentially"
affect the patient's treatment. One of the women who had the unnecessary
mastectomy was in the first category, the other was in the second category.
The remaining 40 patients have been identified and are being contacted by the
hospital.

However, the report says: "The error rate was within the expected range and
thus there is no indication to carry out a further external retrospective
review."

David Astley, chief executive of the East Kent NHS Trust, said: "So far it is
clear that two patients had unnecessary mastectomies. We have seen one of
them and told her and her family what has happened. I've written her a
personal letter of apology on behalf of the hospital and the NHS. The other
lady is abroad and we are trying to get in touch with her."

Mr Astley said women who had breast biopsies examined by the unnamed
histopathologist will have their results re-checked. "We expect this audit to
involve a few hundred women and to take months rather than years to complete.
We are now confident we have got multiple checking procedures in place and an
open culture in which mistakes can be recognised".

Prof Roderick MacSween, President of the Royal College of Pathologists, said:
"The report indicates that the errors fell within the acceptable range.
However there were seven serious mistakes and 35 with a lesser degree of
seriousness. We would regard that as acceptable on a professional basis but
clearly it isn't acceptable to a woman who has been misdiagnosed. The errors
are the result of unavoidable human mistakes."






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