A DAMNING report has laid bare the ‘unforgivable’ blunders by a leading consultant radiologist who failed to spot breast cancer in scores of East Lancashire women.

The independent inquiry found the number of patients affected was far higher than had been thought.

Dr Glenn Anthony Kelly was originally said to have missed breast cancer in 20 patients, but analysis of his patients further back to 2000 found the true figure to be 61.

Six of those women have since died, two from the disease.

It is not known if their prognosis was affected by the diagnosis delays.

The report said Dr Kelly wasn’t ‘sufficiently competent’ to perform a biopsies using ultrasound and instead relied on outdated techniques.

Dr Kelly, who was director of East Lancashire’s breast screening service at the time, has since been suspended and is being investigated by his professional body.

Two woman affected have described the blunders as ‘unforgivable’, while MPs and watchdogs said the hospital trust had ‘totally failed’ patients.

Hospital bosses apologised and said the 40-plus recommendations made by the inquiry would ensure ‘breast cancer screening radiologists perform to a high standard.

The inquiry, carried out by Frank Burns, former chief executive of Wirral Hospital NHS Trust, revealed:

• Dr Kelly ‘had never become proficient’ in the latest diagnostic technique required by guidelines.

• His staff knew this but were ‘inhibited in complaining’ about it because he was the senior radiologist and a director of the unit. ‘Their reluctance to raise concerns formally is understandable but not defensible’, the report said. Mr Burns called on the Department of Health to look at encouraging more openness across the service.

• Of Dr Kelly’s screenings, 92 per cent were found not to have been carried out correctly in line with national guidance.

• There were ‘many failures of clinical and organisational governance’. Senior bosses did not monitor the work of the breast cancer screening unit closely enough and Dr Kelly himself was ‘the person responsible for implementing robust clinical policies’.

• Dr Kelly was meant to have an annual appraisal, but had just three in 18 years. In his 2005 appraisal he asked for training so he could carry out ultrasound biopsies. This request was not fulfilled.

The recommendations relate to improving the training, management and monitoring of staff.

Mr Burns said: “Notwithstanding the many failures of clinical and organisational governance, it is important to be clear that the fundamental reason for the missed cancers was poor diagnostic practice by an individual specialist.

“The personal impact of being recalled for a second assessment on the women affected cannot be overstated.

“Beyond the women directly affected, the extensive local and national publicity about this incident may have undermined the confidence of some women about the thoroughness of breast screening procedures and raised questions about the competence and training of the staff involved.”

Mr Burns said Dr Richard Drabrashian, the new director of the East Lancashire Breast Screening Unit, was ‘highly competent, very experienced and enthusiastic’.

The breast cancer screening blunders were made while the unit was based at Accrington Victoria Hospital, but the service has since been relocated to new facilities at Burnley General Hospital.

Annually, it sees 15,000 women aged over 50 who come for check-ups on a three-yearly cycle.

Mr Burns said: “The women of Blackburn and Burnley can now be fully confident about the quality and safety of the Breast Screening Service at East Lancashire.”

The inquiry found that as early as November 2007 a report that a patient had wrongly been given the all clear by Dr Kelly - referred to in the report as ‘Dr X’ – was uncovered, but treated as an ‘isolated incident’.

Mr Burns was critical that an inquiry was not carried out at this time.

In September 2008 Dr Kelly stepped down from the role of director.

His replacement picked up on ‘grumbling’ from colleagues about him and did an initial audit of Dr Kelly’s screenings, the report said.

Two months later claims of another error was received, prompting a deeper assessment of Dr Kelly.

The report said further cases were identified and the radiologist was withdrawn from the clinic.

But the trust director was not fully informed for four months, while the chief executive was not told anything about the concerns until this time.

Mr Burns said this was ‘wholly inappropriate’.

A full review was then carried out. It found from August 2006 to December 2008, cancer had been missed in 20 out of 276 patients seen by the radiologist.

Cases between 2000 and 2006 were then assessed, uncovering an additional 41 women whose cancer diagnosis was delayed.

Mr Burns found Dr Kelly ‘had never been formally trained in the technique of ultrasound guided biopsies’ and ‘wasn’t sufficiently competent to perform’ them.

‘He is of the view that guidelines are for ‘guidance’ and not a replacement of an individual’s clinical judgement’, the report said.

But Mr Burns wrote that experienced breast radiologists he had spoken to reacted with ‘some incredulity’ that Dr Kelly had never developed these skills recommended by national guidelines.

The technique is seen as more accurate than biopsies guided by two-dimensional X-rays favoured by Dr Kelly, rather the 3D afforded by ultrasounds.

Dr Kelly has not worked for the trust since April 2009.

Rineke Schram, medical director of the trust, said: “The report confirms that the failings which led to women receiving delayed cancer diagnoses all related to a single consultant radiologist within the breast screening unit, and that all other breast screening radiologists working at East Lancashire Hospitals perform to a high standard.

“The trust apologises again to all women affected by this incident, and recognises the added distress it has caused to women already suffering the trauma of breast cancer.

“Lessons have been learned within the East Lancashire Breast Screening Programme and throughout the NHS.”

Ms Schram said Dr Kelly had neglected his personal and professional duty to learn new skills.

She said: “Consultants are highly trained individuals and have a professional responsibility to keep up to date with training.“

Click the link below to read the full Burns report.

Burns report.pdf