Pressures that cause clinical errors: Are recent mistakes in medical test results just bad luck? Judy Jones reports

PATIENTS tested for bone cancer at a Birmingham hospital this year face an agonising few weeks while a team of outside experts supervises double-checks on the diagnoses.

Between 10 and 15 patients have had treatment and surgery postponed until doctors establish whether they really need it. Others, given the all-clear after tissue samples were examined, will fear they may have the disease after all. About 150 bone-tissue biopsy results produced over the past six months by the Royal Orthopaedic Hospital are being checked after it emerged at the weekend that a young boy was mistakenly being given chemotherapy for a cancer that did not exist.

Tomorrow, Archie Malcolm, a consultant pathologist at the Royal Victoria Infirmary, Newcastle upon Tyne and an expert on bone tumours, will convene the first meeting of an independent inquiry ordered by the South Birmingham health authority. Its task will be to find out how the mistake happened, oversee the remaining checks and recommend lessons to be learnt.

It is the second major inquiry ordered this year into suspect NHS hospital laboratory test results. In April, the Argyll and Clyde Health Board ordered the re- examination of 20,000 cervical smear test results at the Inverclyde Royal Hospital. Forty-two women were recalled for clinical investigations. The alert was prompted by the case of a woman found to be suffering from cervical cancer two years after a smear test had given her an all- clear. The health board will not say whether other serious errors have been discovered, pending the outcome of an independent inquiry commissioned by the Scottish Office, which is due to report in August.

The latest scare comes at a time of growing financial pressures on many NHS pathology laboratories. Some face the prospect of their services being hived off to private companies as part of the Government's market testing drive that is spreading through all levels of health service activity.

Dr Malcolm is careful not to prejudge the events that led to the Birmingham inquiry. But he acknowledges that pathologists are being called on to make difficult professional judgements against a background of constant financial and budgetary pressures.

'Bone cancer is a very complex area of pathology,' he said yesterday. 'It can occasionally be very difficult to distinguish between a malignant tumour and a benign one because of varying reactions in the tissue surrounding the area you are looking at. In those cases, another professional opinion will be sought.'

Since the mistake was discovered in late May, about half the 150 Royal Orthopaedic tests earmarked for independent review have been rechecked. No other errors have yet come to light. The process is expected to be completed within four weeks.

Pathology has an undeservedly poor status as a medical speciality. Most people think of pathologists as rather grim- faced doctors who carry out post-mortems and help the police with murder inquiries. Some are, but the majority spend most of their time carrying out routine or emergency diagnostic tests on tissue or blood from patients who are very much alive. Millions of these tests are carried out each year, the vast bulk of them prompting no cause for concern. Standards remain high, partly because of regular peer review and 'quality assurance' random checks.

But the number of surgical biopsies being carried out has increased by 22 per cent in the past five years. The Royal College of Pathologists and the Association of Clinical Pathologists fear that increases in consultant numbers and support staff have failed to keep pace with the extra workload.

According to Dr Malcolm, anecdotal evidence appears to be growing of pathologists exceeding the maximum annual workload of 4,000 tests per consultant, jointly recommended last year by the college and the association. 'If the pathologist gets it wrong, the results can be pretty catastrophic for the individual concerned,' he says. 'Obviously, if the workload increases, the pressures increase and so does the risk of a mistake.'

Over the past year, negotiations between the North Hertfordshire NHS Trust and a Swiss firm seeking to take over the pathology laboratory at the Lister Hospital, Stevenage, have cast a long shadow over the profession. If a deal is struck, many fear it will signal the start of a fragmentation of NHS pathology services, with damaging consequences for training and the maintenance of common and high standards.

Henry Fell, who chairs the British Medical Association's pathology sub- committee, is in no doubt that his speciality is particularly vulnerable to the predations of private-sector operators and the ideologues of market testing in Whitehall and Westminster.

This, he believes, is because of the perceived 'portability' of the speciality - the notion that pathologists do not deal with patients, only bits and pieces of them, and are therefore not as necessary as consultant surgeons, for example, or gynaecologists. 'Some managers think of it as some sort of bolt-on ancillary service, amenable to market testing in the same way as laundry or catering; as if they can put a penny in the slot, press a button and get a result,' Dr Fell protested in a recent letter to colleagues.

He described developments at the Lister Hospital as 'a serious threat' to professional standards, since consultant pathologists would continue to be employed by the trust while their equipment, facilities and support staff came under the control of a private company.

Patients at the Royal Orthopaedic Hospital, caught in an appalling limbo of uncertainty, have more immediate concerns. Until the inquiry reports, it is impossible to say what lay behind the diagnostic errors revealed at the weekend. Yet the rest of us should not panic. What we should remember is that while occasional human errors can never be ruled out, clinical standards are generally high and improving constantly.

(Photograph omitted)