Father, 49, died after his rare cancer was misdiagnosed by NHS pathologist who didn’t seek second opinion because colleague was ‘overworked’, inquest hears
- David Anthony Hulme, 49, died at Derriford Hospital, in Plymouth, in March 2021
- He lost battle to lymphona cancer, just one month after receiving his diagnosis
- The cancer had been misdiagnosed as a rare tissue condition called sarcoidosis
A ‘fantastic father’ died from a rare form of cancer after his NHS pathologist did not seek a second opinion over fears her colleague was too ‘overworked’, an inquest has heard.
Former Royal Navy serviceman David Anthony Hulme, 49, died at Derriford Hospital, Plymouth, in March 2021 – just four weeks after receiving his diagnosis for lymphona.
The potentially fatal cancer, which attacks the lymph system, had been caught too late after being misdiagnosed as sarcoidosis – a rare condition that causes small patches of red and swollen tissue to develop, and which Mr Hulme, a father of two boys, had been diagnosed with in 2014.
A pathologist, who examines manifestations of disease at Derriford Hospital, gave evidence at the inquest this week after she failed to identify signs of cancer in Mr Hulme’s tissue sample.
She admitted that she did not seek a second opinion as the only colleague available to provide one had work ‘up to the ceiling’ and had recently moved to part time hours.
Senior coroner Ian Arrow told the court that a review of staffing levels should be undertaken by the hospital’s hierarchy.
He vowed to write to the hospital’s CEO to insist the staffing issue is addressed.
Former Royal Navy serviceman David Anthony Hulme (pictured with his wife), 49, died at Derriford Hospital in March 2021 – just four weeks after receiving his diagnosis for lymphona.
The pathologist noted that in the summer of 2020 that she had identified signs of ‘granulomatous inflammation’ in Mr Hulmes 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.
She also 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 exact condition was known as ‘high grade B cell lymphoma’ and was located in his right lung after he had previously complained of breathing difficulties and an ongoing cough.
The pathologist giving evidence stated 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 only gained in early 2021 when the pathologist was informed of a ‘change in clinical status’ to Mr Hulme.
The potentially fatal cancer, which attacks the lymph system, had been caught too late after being misdiagnosed as sarcoidosis – a rare condition that causes small patches of red and swollen tissue to develop, and which Mr Hulme, a father-of-two boys (family pictured together), had been diagnosed with in 2014
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 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.
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’.
A senior colleague at Derriford Hospital explained the hospital had completed a ‘root cause analysis’ of the events which led to Mr Hulme’s death.
He stated that the combination of confirmation bias and the complex nature of the case led to individual error in diagnosing Mr Hulme.
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 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.
At the inquest this week, senior coroner Ian Arrow told the court that a review of staffing levels should be undertaken by the hospital’s hierarchy. (Pictured: Derriford Hospital)
The pathologist present at the inquest added that her fellow colleagues believed she ‘acted with integrity at the time’.
Recording a narrative conclusion, Mr Arrow said Mr Hulme had died as a result of ‘high grade B cell lymphoma’, which was a ‘naturally occurring condition’.
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.
Before ending the inquest and addressing the Hulme family, 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.’
Mr Hulme was a father 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, saying: ‘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.’
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