What has gone wrong?
1. Misdiagnosis & incorrect tumour grading
Many patients should have had a re-review of their pathology samples to reconsider the diagnosis and grade of tumour in light of stable scans and prolonged survival.
Examples include:
- Patients who were diagnosed with high grade tumours and given a poor prognosis didn't have their initial samples re-tested or re-evaluated to consider whether the initial diagnosis was accurate.
- One patient being treated for a brain tumour that they never had.
- Treatment decisions being based on inadequate biopsy samples.
These errors shaped neuro-oncology decisions, leading to (in some cases) chemotherapy and radiotherapy that may never have been needed.
Some patients have also been left permanently disabled by the neurosurgical procedures or delays in removing the tumour when it was first identified.
2. Neurosurgical errors & poor clinical decision-making
Investigations highlight failures in neurosurgical care, including:
- Delayed or inappropriate surgical management.
- Decisions being made without sufficient expertise or MDT oversight.
- Failure to challenge incorrect pathology or neuroradiology findings.
- Delayed surgery that allowed tumours to worsen.
- Incorrect or incomplete explanations about prognosis and the need for intervention.
3. Neuroradiology concerns
Concerns have also been raised regarding:
- Incorrect interpretation of tumour appearance or growth pattern.
- Failure to identify stable disease.
- Inaccurate reports suggesting tumour transformation.
Radiology errors often drove inappropriate or unnecessary prolonged treatment plans.
4. Pharmacist failures
Despite NICE Guidance stating that TMZ treatment shouldn’t exceed six months (maximum 12 months), hospital pharmacists continued dispensing it for years without raising concerns.
5. Lack of MDT review & specialist oversight
Diagnosing and treating brain tumours requires coordinated input from neurosurgeons, neuroradiologists, neuropathologists and neuro-oncologists.
Yet across the cases reviewed, many patients had little or no MDT involvement.
This means that there was:
- No challenge to the initial pathology diagnosis to consider why a patient may have survived given the prolonged survivability of many patients.
- No second opinion on radiology.
- No neurosurgical oversight of treatment decisions.
- No collaborative review of prolonged therapy.
- No safeguarding against clinical error.