Derriford Hospital urged to review staffing after man died following cancer misdiagnosis

A coroner has called on Plymouth's main hospital to investigate its staffing levels after a patient died following a misdiagnosis.

David Anthony Hulme, a dad in his 40s, died at Derriford Hospital in March 2021.

Plymouth Coroner's Court heard how clinicians and pathologists at the hospital initially believed Mr Hulme was suffering from sarcoidosis, a rare condition that causes patches of red and swollen tissue to develop. He was diagnosed with the condition in 2014.

He later died a month after being given the correct diagnosis for lymphoma, which is a cancer of the lymph system.

Senior coroner Ian Arrow heard evidence from staff at Derriford Hospital during Mr Hulme's inquest about work related stress and understaffing. On the evidence heard Mr Arrow told the court that a review of staffing levels should be undertaken.

A pathologist, who examines manifestations of disease at Derriford Hospital, gave evidence after she failed to identify signs of cancer in the 49-year-old's tissue sample.

The pathologist noted that in the summer of 2020 that she had identified signs of "granulomatous inflammation" in Mr Hulmes tissue.

She noted 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 that she could rule 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."

Mr Hulme's correct condition was known as "high grade B cell lymphoma" which was in his right lung after he had previously complained of breathing difficulties and an ongoing cough.

The pathologist said that the placement and exact condition of Mr Hulme was extremely rare.

"The diagnosis is very, very, extremely difficult and unprecedented in my career. I have never come across it or even heard of it," she said.

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 done in early 2021 when the pathologist was informed of a "change in clinical status" to Mr Hulme.

A consultant pathologist at Royal Brompton Hospital in London informed staff at Derriford Hospital that he was "worried that it could be lymphoma".

Although Mr Hulme 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 the Hulme family, pressed the pathologist on why she had not sought a second opinion at the time of the first examination. She said: "I wish that I had sought a second opinion. I apologise to the family for that."

The pathologist stated the only colleague at the 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.

The pathologist also acknowledged that in her occupation doctors are not "always good at showing uncertainty" and instead are taught to "come down on one side".

Derriford Hospital has since completed a "root cause analysis" of the events which led to Mr Hulme's death. A senior colleague stated that the combination of confirmation bias and the complex nature of the case led to individual error in diagnosing Mr Hulme.

The analysis also uncovered a series of problems, contributory factors and recommendations going forward to ensure a similar incident would not happen again. Included in 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 which would help pathologists seek a second opinion. A new forum has also been set up which will see pathologists meet quarterly to discuss difficult cases, specifically the problems and lessons they had learnt from working with the patient.

Giving a narrative conclusion Mr Arrow said that Mr Hulme died from cancer. He informed those giving evidence that he would be writing to the CEO of Derriford Hospital with the advice that staffing levels should be investigated.Mr Hulme was a dad to Kieran and Joe, aged 21 and 15 respectively and had previously served in the Royal Navy. Mr Hulme's wife described her partner of 19 years: "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.

"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."