PERFORMANCE: An independent probe has concluded West Hertfordshire Hospitals Trust missed an opportunity to uncover major problems in its cancer waiting times management due to poor complaints handling and “lack of continuity in leadership”.

The review was commissioned by the Trust Development Authority to determine why the trust had failed to meet national and local guidance for managing its two week waiting targets for cancer pathways.

Its report concludes that “inconsistent compliance” with national standards “had been an issue for several years without the knowledge of senior personnel” at the trust.

The trust apologised in February after admitting the diagnosis of more than 800 patients suspected of having cancer could have been delayed because of an administrative error.

A number of patients who failed to attend their first appointment after urgent referral for cancer tests between January 2010 and November 2013 were not offered a second appointment. Some were discharged by the trust.

West Hertfordshire said at least one person may have died as a result of the mistakes.

It learned of the error last November, after chief executive Samantha Jones – who joined the trust in February 2013 – introduced a new management team.

However, the review found the trust had a missed an opportunity to uncover the problem in November 2012, when a GP formally complained that patients with suspected cancer on a two week wait pathway had been discharged after failing to attend one session.  

The trust’s formal complaint response in July 2013 “acknowledged the issues and committed to actions to resolve them”, but the review found that “progress was not followed up” because “the appropriate systems were not in place to deal with complaints management at that time and due to a lack of continuity in leadership and ownership to address the issues”.

The review made a raft of recommendations, including the development of a new cancer plan by the trust, and improvement to its IT and communications infrastructure.

Ms Jones said: “I apologise unreservedly to the patients and families affected and wish to assure them that we have already put failsafe mechanisms in place to stop these issues arising again.”

Stephen Ramsden, who chaired the investigation panel conducting the review, said its purpose was “not to apportion blame but to establish the factors that led to local and national guidance not being followed”.