MISDIAGNOSIS ‘Fit and healthy’ man died of complications after operation to treat cancer he NEVER had
A “FIT and healthy” 84-year-old died in hospital after undergoing a high-risk operation for a cancer he ever had, according to a coroner.
Alan Soane died on June 26, 2023, following complications from surgery to treat an incorrect diagnosis of a rare form of cancer.
In March 2023, the elderly man underwent an endoscopy and a biopsy of his small intestine at his local hospital in Essex.
The biopsy concluded it was "most likely" that Mr Soane had a “differentiated adenocarcinoma”, a type of cancer that grows in glands that line the insides of the organ.
Mr Soane was referred to the Royal London Hospital in Whitechapel in May, where doctors diagnosed him with cancer of the duodenum - the first part of the small intestine, which receives food from your stomach during digestion.
The medical team conducted an immunohistochemical test, which checks for cancer markers, to reach their verdict.However, they didn't do any further biopsy tests to reach this conclusion, according to a Prevention of Future Deaths report issued by the coroner for Inner North London, Ian Potter.
Following the diagnosis, Mr Soane agreed to complex surgery known as a “Whipple” procedure.
The high-risk operation involves removing the head of the pancreas, the gall bladder, the bile duct and the first part of the small intestine.
The procedure comes with a 10 per cent chance of dying either on the operating table or not recovering and a five per cent chance of surviving up to five years, even if it is successful.The operation is associated with many complications, including difficulty digesting, infection or bleeding from the gastroduodenal artery.
Mr Soane died on June 26 “as a direct result of known complications” of the procedure, the report said.
He would “not have been offered Whipples surgery had it not been for the incorrect diagnosis provided”, it added.
Consultatant shortage
In the report, Mr Potter raised concerns that Barts Health NHS Trust, which runs the Royal London, did not have a consultant histopathologist to help doctors.
Histopathologists study organs, tissues, cells and genetics to help provide a diagnosis
Mr Potter said, "It was acknowledged" that the specialist's absence at the meetings led to the misdiagnosis.
He also noted that the issue had been on the Trust's risk register for over five years.
Still, recruitment exercises had failed, with 25 per cent of Consultant Histopathologist roles vacant nationally.
"In short, there is a national shortage of Consultant Histopathologists," Mr Potter wrote in the report to NHS England.
“The concern is that a national shortage of consultant histopathologists puts a widespread proportion of the patient population at a significant risk.”
Mr Potter said he was “reassured that the individual NHS Trust had made continued efforts to reduce the risks they identified” by attempting to recruit to the vacant post.
However, he added that he was “not reassured that action has been taken at a national level” to reduce the consultant shortage.
What is duodenal cancer?
Duodenal cancer is a tumour in the first portion of your small intestine, which receives food from your stomach during digestion.
It can prevent the intestine from properly digesting food and even block food from passing through.
For this reason, symptoms can include:
- Abdominal pain
- Acid reflux
- Blood in your poo
- Constipation
- Nausea or vomiting
- Unexplained weight loss
But many people won't notice any signs in the early stages of the disease.
Duodenal cancer is rare, making up less than 0.5 per cent of gastrointestinal cancer cases.
There is no figure for the number of people affected by duodenal cancer every year in the UK, but there are about 1,800 small intestine cancer cases and 555 deaths annually.
Anyone can develop duodenal cancer, but men aged 60 to 80 with other intestinal conditions like coeliac disease and Crohn's disease are thought to be at increased risk.
Source: Cleveland Clinic and Cancer Research UK
An NHS spokesperson said: “NHS England extends its deepest sympathies to the family and friends of Alan Soane.
"We are carefully considering the Prevention of Future Deaths Report sent to us by the coroner and will respond in due course.”The Sun has contacted Barts Health NHS Trust for comment.
NHS England has until May 28, 2024, to respond to the coroner’s report.
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