Brabners' lawyers uncover fresh concerns in cancer care across Coventry, Warwickshire & Birmingham

At-a-glance:

• New evidence has emerged relating to misdiagnoses of brain tumour samples at University Hospitals Birmingham which led to unnecessary or harmful cancer treatment at University Hospitals Coventry and Warwickshire (UHCW) NHS Trust.
• Concerns now arise from neuroradiological interpretation of tumours and tumour growth pattern leading to poor decision making by neurosurgeons on treatment for some patients.
• Over 30 patients are now taking legal action against UHCW, all of which were under the care of now retired neurooncologist, Professor Ian Brown, Ian Edwards and others who promoted prolonged and unnecessary temozolomide chemotherapy, contrary to NICE guidance. This has subsequently been acknowledged in writing by the Trust’s CEO.
• We're raising the alarm on systematic issues with care at UHCW and with the grading and reporting of tumours at UHB.

Our lawyers who are representing current and former patients of University Hospitals Coventry and Warwickshire NHS Trust (UHCW) and University Hospitals Birmingham NHS Trust (UHB) have identified concerns about tumour misdiagnoses across both trusts. We're now calling on them to proactively contact all potentially affected patients, commit to sharing findings transparently and take decisive action to prevent such failings happening again.

Following the exposure of a scandal involving more than 30 patients given unnecessary chemotherapy earlier this year, new evidence has come to light that points to a wider pattern of harm across the two NHS trusts. We're representing more than 30 current and former patients and have uncovered clear evidence of misdiagnoses by pathology services at University Hospitals Birmingham. In some cases these misdiagnoses directly shaped treatment decisions in Coventry — leading to them being referred under the treatment of Professor Brown and his team and undergoing years of unnecessary chemotherapy. Investigations have also revealed substandard neuroradiology diagnosis, neurosurgical treatment and failures by pharmacists to challenge prolonged treatment, all of which have led to devastating lifelong consequential outcomes for some patients.

Misdiagnosis concerns 

Earlier this year, cases at UHCW made national news when it emerged that brain tumour patients were being given the chemotherapy drug, temozolomide (sold under the brand name Temodar), for periods far exceeding recommended guidance. In some cases, patients received the drug for more than a decade, despite guidelines recommending a maximum of twelve months and little evidence of benefit for prolonged use. This regime was promoted as lifesaving, yet the Trust has since confirmed it was neither evidence-based nor aligned with NICE guidance.

Through careful and forensic review of patient records and collaboration with leading experts in their field, Brabners' ongoing investigation shows these cases are just the tip of the iceberg. Our work with affected patients has identified a systematic problem with how tumours were diagnosed, graded and treated. 

In all cases we've reviewed, pathologists at University Hospitals Birmingham were responsible for analysing biopsies from UHCW patients. Independent reviews commissioned by Brabners shows that in a number of cases, patients were told they had aggressive, high-grade tumours when the evidence actually pointed to slower-growing, lower-grade disease or even a different condition that wouldn't require any radiotherapy or chemotherapy treatment. We believe that neurosurgical decisions were sometimes made without adequate experience, oversight or multidisciplinary team review, resulting in avoidable harm, permanent disability and reduced life expectancy. Misdiagnoses by pathologists resulted in inappropriate and harmful treatment decisions, with some patients receiving aggressive therapies for benign or low-grade tumours or in one case, the patient never had a brain tumour at all.

In at least one case, a patient was diagnosed with aggressive brain cancer despite the biopsy sample being too small to reach a reliable conclusion. That patient then underwent radiotherapy followed by over ten years of gruelling chemotherapy that was later deemed unnecessary. Other patients were told their tumours were transforming into more dangerous forms, prompting aggressive treatment, despite stable scans for years and no evidence to support that conclusion.

As a result, patients endured prolonged chemotherapy with serious side effects — including infertility, chronic fatigue, increased infection risk and damage to their long-term health — for conditions they may not have had or which required far less aggressive intervention. 

Pharmacist failures

Our investigations also highlight the failure of pharmacists to challenge or prevent the dispensing of temozolomide far beyond the duration recommended by NICE guidance.

Patients routinely prescribed temozolomide attended monthly clinic appointments at UHCW and were given prescriptions to collect from the hospital pharmacy. Each prescription was checked and signed off by Trust pharmacists before being dispensed, even though many patients had been taking the medication for far longer than guidance recommended — a process that continued, in some cases, for over a decade. 

Pharmacists are a critical safeguard in the healthcare system, responsible for identifying prescribing issues and challenging treatments that do not align with clinical guidance. They're expected to be familiar with NICE guidance relevant to the medications they dispense. The prolonged administration of temozolomide should have been questioned or escalated, particularly given the repeated, routine dispensing over many years. 

Views from our experts

Our own Fiona Tinsley (Partner and Head of Clinical Negligence & Serious Injury), said: 

"What began as concerns about chemotherapy in Coventry now points to systemic failings across two NHS trusts, involving pathologists at UHB and neuro-oncology clinicians, neurosurgeons, neuroradiologists, clinical nurse specialists and pharmacists at UHCW. 

Multiple regulators are now investigating individual clinicians and the Trust itself, including the General Medical Council, the General Pharmaceutical Council and the Care Quality Commission and The Royal College of Physicians. Yet the review by the RCP falls far short of what’s needed. Reviews have been limited in scope, with no input sought from the affected patients or their families. This cannot be seen as a meaningful exercise in accountability — patients and families have been denied transparency and candour, with the Trust failing to provide honest explanations, apologies or meaningful engagement.

Without the bravery of so many patients in coming forward, the extent of the failings across these two trusts might never have been recognised. The human cost has been devastating. People were told they would have months to live without treatment and endured years of debilitating treatment, believing it was keeping them alive. The burden of these failures has been profound. Patients have suffered physical, psychological and financial harm, including loss of career, fertility and quality of life. 

For many there is also no end in sight, with some patients becoming infertile and going into early menopause and one developing secondary leukaemia requiring a stem cell transplant. All patients involved have also been placed at increased risk of secondary cancers. These patients deserve answers and assurance that the NHS has learned from this, so it never happens again.

We're calling on both trusts to proactively identify and contact every patient who may have been affected, to commit to sharing findings transparently and to take clear, meaningful action to ensure this never happens again. These patients deserve answers, accountability and assurance that every lesson is being learned. This is in the public interest."

What to do if you've been affected

Following the new concerns, we're encouraging any current or former patients who believe they may have been affected to review their treatment history and — if they wish — to seek independent advice.

As the leading national firm in uncovering and addressing negligence in these cases relating to brain tumours and neurosurgery care, we can help you to understand what went wrong and how to seek justice.

Our specialist team provides:

• Full review of tumour pathology, scan interpretation and neurosurgical decision-making.
• Expert opinions from neurosurgeons, neuroradiologists, neuro-oncologists and neuropathologists.
• Explanation of what went wrong and where errors occurred.
• Guidance through NHS complaints and legal claims.
• Support in securing compensation for the physical, emotional and financial impact.

You can speak to us confidentially for free, no-obligation advice. We can also come to meet you where you’re located.

We offer a free initial consultation and most claims proceed under a ‘no win, no fee’ agreement.

Taking the first step can make all the difference. Talk to us by giving us a call on 0333 004 4488, sending us an email at medneg@brabners.com or completing our contact form.