A report prompted by concerns over breast cancer testing results at Sherwood Forest Hospitals Foundation Trust has criticised management and communication within the organisation.

The Care Quality Commission (CQC) report, published today, found that the trust’s Kings Mill Hospital was meeting the national standard concerning the welfare of people. However, it said that processes to assess and assure the trust of its own service quality had not been effective or robust enough.

A detailed investigation into the trust was launched in October last year after 79 women with breast cancer were recalled due to irregularities surrounding test results carried out at Kings Mill.

Health care regulator, Monitor, had also raised concerns over the trust.

The CQC report reached the following conclusions:

  • There had been poor communication between pathologists and the trust’s board of directors and weaknesses in communication between the clinical governance committee and board of directors.
  • The pathology department was without a leader for five years between 2003 and 2007, with the role being covered by locum staff, and a number of permanent posts were not filled.
  • Equipment used by the department was identified as outdated and manual techniques were used in the department, leading to inconsistent results.
  • Decision making in the clinical governance committee was not always clear.
  • The hospital’s action plan in relation to mortality rates was not being clearly monitored by the trust board and had not been subject to in-depth analysis.
  • Processes to detect changes in performance or risk were not robust enough.

Dr Andrea Gordon, CQC deputy director of operations (regions), said: “Kings Mill Hospital must make sure it has robust processes in place to assure itself that it can manage and identify any risks or issues. Where issues are identified these have to be clearly communicated to trust leaders so any necessary action can be taken. It is imperative that any improvements the trust makes are sustainable and maintained for the future.”

As part of the inspection, The Royal College of Pathologists was brought in to look at whether women with breast cancer might have been given incorrect test results between 2004 and 2011. The college’s report into its investigation is also published on Friday.

A statement from the Royal College of Pathologists said: “The findings of our report have implications far wider than Sherwood Forest NHS Foundation Trust. The report raises important questions about the organisation of pathology departments and their workload, and the effectiveness of pathology quality assurance.”