Seamus Edney at S J Edney Solicitors is acting for the family of the late Mr Stephen Hall who sadly died on the 20 March 2020.

They are unhappy with treatment which he received at Great Western Hospital in Swindon during 2016.

Briefly, during July 2016, Mr Hall had been unwell complaining of shortness of breath, vomiting and abdominal swelling. His GP referred him to hospital where he was admitted overnight for observation.

As part of their investigation, the hospital took a sample of his pericardial fluid. This was sent to Oxford for analysis and then returned to Swindon but the results were not acted upon. It was thought that he had been suffering from viral pericarditis.

Unbeknown to Mr Hall, the cytology of the pericardial fluid was reported to show metastatic non-small cell lung cancer (adenocarcinoma). His treating doctors at the time were not notified of these results.

At the beginning of August 2018, Mr Hall consulted his GP again complaining of a persistent cough. A CT scan showed an area of plural abnormality and he was referred to the hospital again for investigation.

During September 2018, further tests were undertaken including a biopsy and he was now advised that he had a Stage 4 non-small cell lung cancer.

He was then told by the hospital (as part of their duty of candour) of the 2016 test results following his pericardial fluid results.

Mr Hall and his family were devastated with this news – not only had he just been told that he had lung cancer but this diagnosis could have been made two years earlier. Not unreasonably, he suspected an earlier diagnosis/treatment in 2016 may have improved the outcome for him.

The hospital promised to look into this oversight by carrying out their own Internal Review and they would then report back to Mr Hall with their findings. He was put on immunotherapy for treatment.

Mr Hall also made a formal complaint via PALS against the hospital during 2019. The family are still waiting to receive a response.

The shear awfulness of this “double whammy” for the family is hard to describe in words.

The hospital have acknowledged that there was a failure in the care provided to Mr Hall during 2016 but they have still not completed their Internal Review into why this was allowed to happen or respond to Mr Hall’s complaint.

Mr Hall realised that the hospital could not do anything for him now, in light of his advanced cancer diagnosis, but he hoped that speedy lessons could be learnt by the hospital to try and avoid it from happening to other patients and their families. He was worried that this mistake had not been a one-off and that other existing patients had not been told of a life threatening illness.

This two year delay was very upsetting for Mr Hall and his family causing them unnecessary stress and anguish. He only consulted a solicitor at the beginning of 2020 as he felt he did not have any other option. He said to Mr Edney shortly before he died:

I have spent countless hours at night agonising over what may have been missed – a mother may have lost a son or a husband, a daughter her father. My own family may very well have lost me or I may have been too incapacitated to deal with this whole situation.

This on top of the very real mental and physical damage that has been caused to me and my family through changes to me and my lifestyle. Despite all that, Great Western Hospital complaint staff seem totally oblivious to the effects their ineptitude has had on us and for all I know, many other people in the same situation”.

STATEMENT OF HIS WIFE

Melanie (his widow)

In September 2018 Steve was given his biopsy results which showed adenocarcinoma cells, this was a devastating blow for us. However, as a “Duty of Candour” we were then informed that cancer cells were also found to be present in the pericardial fluid aspirate, which was drained in June 2016, but the results were not picked up and actioned at that time. This was a shocking revelation and a double blow having just been given such a diagnosis. At the same time we were informed that an IR1 (internal investigation) would be raised re this and that we would be notified of the outcome and progress of this in due course. The doctor also explained that the 2016 sample had been sent to Oxford for cytology and that this was usually done at GWH except when their own cytologist was on holiday. We were told GWH had been unable to recruit a second cytologist despite trying for some time, but that sending samples to Oxford in her absence was an arrangement that was usual practice at such times, but that for some reason on this occasion the result was not picked up on its return to GWH.

The Impact on family:

We reeled with the awfulness of the double whammy, it is hard to find the words to articulate quite how we felt as we processed all the implications of both ghastly nuggets of news. We were truly appalled at how something of such monumental importance and significance could have been overlooked in a system designed to serve and protect the best interests of patients. Steve’s horror was not just for himself and our family, he was incensed for all the other people who might similarly have been undiagnosed during that fortnight, and whose cancer might have progressed more rapidly and detrimentally during two years . He was tormented by the thought that they might not have had any opportunity to have treatment at all. He lost sleep over this.

For myself, I lost sleep over the prospect of losing HIM, I was numb, shellshocked, sickened at what I perceived as two lost years of time. It was time Steve and I should have spent intensively together and with family, dropping all else and fulfilling some of our dreams. Arguably we should all live like that as much of the time as we can, but in truth we do not, we cannot, as other life events intrude. His diagnosis, when it eventually came in late summer of 2018, coincided with the traumatic death of my mother, followed by the death of my father only 11 months later. Emotionally my family were at a low ebb, it inhibited our ability to properly do justice to Steve’s limited time, we were a family all at sea. If only we had had those two years from 2016-2018.

Steve and I wanted to take our touring caravan and explore the beauty of the British Isles, it was our much talked of retirement plan, and we would have brought this forward. We did not get the chance to do this after my mother’s death, as I was then a full time carer for my increasingly fragile elderly father.

Within 18 months we have lost three vital members of our family, and whilst an earlier diagnosis for Steve may not have changed the unhappy circumstance of his death, it would at least have afforded us more time when we were less emotionally encumbered.

I remain incredulous and demoralised at how GWH have dealt with their ignominious internal investigation. It is as if Steve and his results really did not matter, that their woeful oversight was an error of no significance. Regrettably, Steve died with absolutely no feedback to explain why this had happened, this seems particularly heartless from a caring institution, as if they are somehow not accountable for their actions or omissions. Knowing the terminal nature of Steve’s diagnosis, I would have expected the risk management team to have dealt with this investigation in a timely, solicitous manner, but on the contrary, they have dragged their heels and delayed at every opportunity and met not a single promised deadline. Whatever the outcome, it is too late to tell my husband now, it is an insulting shambles and beggars belief doing us all a grave disservice.

18th September 2020