A DAD died of cancer after overworked nurses claimed they were too busy to get a second opinion.
David Anthony Hulme, 49, tragically passed away at Derriford Hospital, Plymouth, in March 2021 following a misdiagnosis.
It came one month after he received the correct diagnosis for lymphoma, a cancer of the lymph system, reports Plymouth Live.
Clinicians and pathologists at the hospital previously believed that David was suffering from sarcoidosis, a rare condition that causes small patches of red and swollen tissue to develop.
The dad-of-two was diagnosed with the condition in 2014.
Senior coroner Ian Arrow heard evidence from staff at Derriford Hospital about work related stress and understaffing.
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On the evidence heard in the hearing Mr Arrow informed the court that a review of staffing levels should be undertaken by the hospital’s hierarchy.
A pathologist, who examines manifestations of disease at Derriford Hospital, gave evidence at the inquest after she failed to identify signs of cancer in David’s tissue sample.
She noted that in the summer of 2020 that she had identified signs of “granulomatous inflammation” in his tissue.
This was in keeping with the diagnosis of sarcoidosis and can be a sign of cell injury caused by a variety of conditions including infection, autoimmune, toxic, allergic, drug, and neoplastic condition.
The pathologist also stated that due to the high inflammation it was extremely hard to examine the samples and by using the clinical history of the patient she felt comfortable ruling out cancer.
She said: “I did not feel in my experience that this was a malignant condition. At the time I felt it was benign.”
David’s condition was known as “high grade B cell lymphoma” and was located in his right lung following his previous complaints of breathing difficulties and an ongoing cough.
The pathologist giving evidence stated that the placement and exact condition of Mr Hulme was extremely rare.
She said: “The diagnosis is very, very, extremely difficult and unprecedented in my career. I have never come across it or even heard of it.”
She told the hearing that in her job she is “reliant on clinical context” and due to the previous diagnosis of sarcoidosis she felt that was the most likely cause of Mr Hulme’s condition.
A reassessment and a second opinion of the tissue sample was only gained in early 2021 when the pathologist was informed of a “change in clinical status” to David.
A consultant pathologist at Royal Brompton Hospital in London informed staff at Derriford Hospital that he was “worried that it could be lymphoma”.
Although David did receive treatment for lymphoma prior to his death it was unable to prolong his life longer than a month.
Ms Carmell, a legal representative of David’s family, pressed the pathologist on why she had not sought a second opinion at the time of the first examination.
She responded saying: “I wish that I had sought a second opinion. I apologise to the family for that.”
The pathologist stated the only work colleague at Derriford Hospital who would have been able to look at the sample was “overworked with work up to his ceiling” and had recently swapped to working part-time hours.
She also acknowledged that in her occupation doctors are not “always good at showing uncertainty” and are taught to “come down on one side”.
A senior colleague at Derriford Hospital explained the hospital had completed a “root cause analysis” of the events which led to David’s death.
He stated that the combination of confirmation bias and the complex nature of the case led to individual error in diagnosing David.
The analysis conducted also uncovered a series of problems, contributory factors and recommendations going forward to ensure a similar incident would not happen again.
Included within the findings was evidence of increased staff workload, a lack of consultants and a lack of formal training.
Going forward, the senior colleague stated that a new operating system had been developed to help pathologists seek a second opinion.
A new forum has also been set up which will see pathologists meet quarterly to discuss difficult cases.
Giving a narrative conclusion Mr Arrow said that Mr Hulme died from cancer.
Before ending the inquest, Mr Arrow said: “I would like the opportunity to pass on my condolences to the family. I am very sorry to have heard of your loss.”
David, a dad to Kieran and Joe, aged 21 and 15 respectively, previously served in the Royal Navy and was described by his partner of 19 years as a “fantastic husband”.
She said: “He was such a fantastic husband and dad to our boys, and to this day I still feel myself going to speak to him and then realising he’s not here anymore. We all miss him every single day.
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“Since he died, I feel like time has stood still for me. He was my soulmate and I really can’t imagine the rest of my life without him.
“I know nothing will ever bring him back, and I know reliving it all at the inquest will be tough but I hope that it will at least provide us with the answers we need.”
