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Monday, 15 April, 2002, 09:25 GMT 10:25 UK
Breast screening errors 'unacceptable'
Breast screening
Evidence suggests screening saves lives
An inquiry into a breast screening programme in which 11 women were wrongly given the all-clear has said there were "unacceptable and avoidable failures".

The Department of Health has responded by saying it is to review the national breast screening programme.

The report, by health standards watchdog the Commission for Health Improvement looked at errors at the West of London Screening Service, run by Hammersmith Hospitals NHS Trust.

One woman, whose diagnosis was delayed for 15 months, has subsequently died of breast cancer.

We need to ensure that lessons are learned across the entire breast screening service so that it does not happen again

Peter Homa, CHI
Her family, and six of the other women affected, are considering legal action.

CHI said the report was a "wake-up call for the whole NHS". It makes 36 recommendations, and says lessons from events at West London need to be learned both there and nationally.

Lost x-rays

CHI said a number of factors led to the errors including files marked in a confusing way, with scope for women needing a routine check in three years time to be mixed up with women who needed an immediate recall.

CHI said the service also failed to learn from previous mistakes there and elsewhere in the service.

Lack of leadership and staff shortages also hindered the work of the unit, the report said.

Recommendations for West London
Review the clinical director's role
Timetable for implementing the NHS Breast Screening Programme's quality management guidelines
Improve lines of accountability in the service
Dr Linda Patterson, CHI's medical director, said the right management and accountability systems had to be in place: "These things are important to make sure that the patient gets the right results and the care that they need."

Derek Smith, chief executive of Hammersmith Hospitals NHS trust accepted the report's findings and apologised to the women affected and their families.

He said: "There were a series of administrative breakdowns.

"These are very complicated services to run and it's very easy for things to go wrong."

Action taken

The trust blamed the errors on a backlog of work caused by increasing demand and staff shortages.

A new management team has been brought into the unit.

My first reaction was just to be devastated - the anger came later.

Eve Acorn, patient
CHI acknowledges the hospital has already taken on more staff, improved management and accountability and clarified notification procedures.

But CHI recommends further action including looking at the role and responsibilities of the clinical director, plus more quality checks.

Nationally, CHI says hospital trusts should check the screening service they use abides by national guidelines.

Wrong letter

Peter Homa, CHI chief executive, said no single person was to blame. "A series of basic errors led to 11 women being harmed by the NHS. This is unacceptable.

"National guidance was neglected, despite attention being drawn to it and despite files having been mixed up in the past.

"Accountabilities and responsibilities were unclear and ambiguous resulting in confusion about who was responsible for what.

"We need to ensure that lessons are learned across the entire breast screening service so that it does not happen again."

The inquiry was launched by CHI last April.

More than 174,000 cases, dating back to 1993, were reviewed.

Eva Acorn:
Eva Acorn: "devastated" by events
Of the 11 given the all-clear, six had found signs of breast cancer and were being treated by the time the results emerged.

The other five were offered treatment including radiotherapy and chemotherapy.

The mistakes came to light after a woman was sent the wrong letter telling her to return to hospital in three years instead of immediately.

Eve Acorn, 60, a retired teacher and amateur artist, refused to believe doctors who gave her the all clear and insisted on an operation which showed she had cancer.

She told the BBC: "My first reaction was just to be devastated. The anger came later.

"But I am furious about it, particularly since they haven't apologised to me."

Dr Liam Fox, shadow health secretary said: "The crisis in NHS pathology runs more widely than the Hammersmith NHS trust.

"This is a widespread and extremely serious situation which is affecting all parts of the NHS."

Derek Smith, Hammersmith Hospitals NHS Trust
"We apologise sincerely to all the women who were affected"

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