A woman wrongly given the all-clear by a consultant radiologist who misread her breast cancer scan results has died from the disease, it emerged last night.
The patient, who has not been named, was one of 28 women whose mammograms were misreported at a hospital in Greater Manchester. She died after the mistake went unnoticed for at least three months. Another woman's breast cancer was only noticed two years after she was given the all-clear, it emerged.
The mistakes by a consultant radiologist sparked a review of nearly 2,500 mammograms by bosses at the Trafford General hospital and North Manchester General hospital.
A total of 176 women had to be recalled and re-tested after the mistake was identified in April 2005. Of the 28 wrongly given the all-clear, 18 were told that their chances of surviving were "significantly" worsened because the delay in spotting the error was more than three months.
The details came to light as the NHS North West published a report into the scandal, criticising hospital procedures and saying that errors could have been spotted earlier if a clinical audit of the radiologist's work had been ordered after his colleagues raised concerns to their bosses in November 2003.
The author of the report, Professor Mark Baker, blamed the errors on the radiologist, referred to as Dr A in the report, adding that his failure was "compounded by systematic weaknesses in Trafford NHS Trust".
The doctor's work had quickly aroused suspicion, but he was allowed to continue working for 17 months, despite the concerns expressed by his colleagues. Hospital staff did not trust Dr A's conclusions and would check with other radiographers before informing patients of results, according to the report.
Prof Baker said: "Dr A's practice in the breast service in Trafford Healthcare Trust almost immediately aroused concern amongst the mammography radiographers. There are divided views on whether his non-breast work was of an acceptable standard. Some indicators suggest that he made extraordinary errors and used extravagant suggestions for the cause of image findings."
He concluded that "the precipitating cause of the misreading of the mammograms was the personal failure of a radiologist. However, this was exacerbated by his isolated working in a small imaging department and a generally weak diagnostic setting in the breast service," added Prof Baker.
He added that Dr A had worked single-handed in Trafford and did not have colleagues routinely double or triple reporting his findings as he had had in previous hospitals.
Dr A is currently the subject of a General Medical Council investigation. He was suspended in April 2005 after the mistakes came to light.
Health chiefs have refused to reveal details regarding the condition of any of the 17 other women affected, due to patient confidentiality rules.
Of the 28 women who had delays in getting their breast disease diagnosed, 25 were patients from Trafford General, and three from North Manchester General.
Twenty-one were diagnosed with invasive breast cancer, six had benign breast disease, and one had a treatable tumour.
The hospitals were at pains to point out that the recalled patients were women who had been referred for the tests by their GP - not those routinely checked by the national breast screening programme.
A helpline has been set up for anyone with concerns regarding their breast scans. The number is 0161 455 0059.