A “CATASTROPHIC” and “irreversible” mistake was made when a patient’s lung cancer was not diagnosed at an early stage.
The patient had been referred to Brighton and Sussex University Hospitals NHS Trust because he had severe anaemia.
A growth showed up on an X-ray but it was missed and when the patient was eventually diagnosed it was too late and he is now terminally ill.
The man, named only as Brian, was referred to the trust in January 2010.
He was given a blood transfusion and investigations were carried out to try and establish the cause of his condition, which seemed to suggest he was bleeding internally.
He also had a chest X-ray because he was a life-long smoker and had recently lost weight.
Brian was feeling much better the next day and as the investigations of his stomach had not found any issues, he was discharged with an outpatients appointment for the digestive diseases department.
But nobody had followed up his chest X-ray before he was discharged.
In January 2013 Brian was referred to the trust again for a cough he could not shake off and an X-ray showed a mass in his lung.
When the original chest X-ray from 2010 was looked at it became apparent that a smaller and less obvious mass was there at that time.
The patient’s story emerged when he spoke to trust board members.
It cannot be said for certain whether an early diagnosis would have prevented the cancer from being terminal.
But trust chief executive Matthew Kershaw said there had been a clinical error in the patient’s treatment.
In a message to staff, Mr Kershaw said the board had responsibility for the trust’s services.
“We can never know for certain what treatment would have been possible had Brian’s lung cancer been diagnosed in 2010 as opposed to 2013, by which time it was inoperable and terminal, but what we do know is that we made a catastrophic and irreversible clinical error.
“The extensive changes we have made to our systems will reduce the likelihood of the same mistake happening again.
“But despite our best efforts people are fallible, they get distracted, they forget things and they make mistakes.
“That is why we need to have the courage to design systems which presume people will make mistakes and, when they do, have the courage to talk about them openly and honestly.
“That is the only way we will protect our patients from harm.”