Margaret Jones had a CT scan at GenesisCare in Portsmouth in February 2019, after she was diagnosed with breast cancer and was being prepared for radiotherapy.
The scan revealed a cause for concern in her right lung – but due to failings in GenesisCare’s internal processes, this was never passed on. Had Margaret’s cancer been identified at this stage, medical evidence supports that it would most likely have been treatable.
Margaret, from Fareham, was eventually diagnosed with stage 4 lung cancer in December 2023, which by then had spread to her brain and bones. She experienced significant suffering and loss of mobility as her condition deteriorated, and the grandmother – also mother to two daughters and a son - died in August this year, aged 76.
“We are so angry, devastated, absolutely lost without our mum. She was the centre of our world, and to lose her in such a preventable way, and to know her cancer was treatable, has destroyed our whole world. This need not have happened,” says her daughter Karen.
“Mum put her absolute faith in the medical profession, she would never have doubted what the professionals told her. But what has happened here is a catastrophic failure, and was utterly devastating for her to find out about.”
Her other daughter, Sarah, added: “Mum didn’t want this to happen to anyone else, so we as a family are speaking out in the hope we can stop this happening again, to save even one more family being torn apart as we have been.”
Margaret, a mother of three, was referred to GenesisCare, an oncology treatment provider, by Spire Hospital Portsmouth, where she paid privately for her care. Ahead of the course of radiotherapy she was due to undergo for her breast cancer, she had a preparatory CT scan – which identified an area of concern in her upper right lung.
However, due to a breakdown in communication – which an internal investigation by GenesisCare has failed to get to the bottom of, due to missing emails and medical records, and a lack of an audit trail – this was not escalated to Margaret’s oncologist.
Among the numerous opportunities to flag this up include disputes over which members of staff were involved, whether a phone call was made to pass on this information, and whether a radiology report was printed out and put into the consultant clinical oncologist’s pigeon hole.
GenesisCare – which has referred itself to the CQC over its role in this case – said that due to the lack of audit trail, and amount of time which has passed since 2019, it cannot be certain as to what happened.
However, Karen says: “I don’t know how an organisation can operate without an audit trail, particularly one that deals in life or death information. This way of working is not fit for purpose. They have fundamentally failed our mum.
“The failures are just so basic. When you’re passing on information of this kind of importance, you request an email read receipt, to make sure it has been passed on. The continuity of information is absolutely critical in situations like this. And I cannot believe in this day and age we are relying on printed information in pigeon holes – how can this be part of a modern and fit for purpose healthcare system?
“Without proper processes in place, this could absolutely happen again, and that is really terrifying for us. We need proper answers so we can fix the root cause of what happened here.”
Margaret had a chest X ray in 2022 for a continuous cough. The results were reported as clear, despite it later being confirmed that the tumour was also visible on those scans. She returned to seek medical attention the following year after experiencing weight loss and a lack of appetite.
Her devastating diagnosis was made in December 2023, at which time doctors disclosed that her cancer may have been known about earlier.
Sarah adds: “We asked to see her medical records, and this showed us it had been the case. As a family, we really want more people to be aware they can ask for their medical records and see copies of their scans. Of course if proper processes are in place you shouldn’t have to do this, but we want people to ask for a second opinion if they have concerns, and not to be afraid to do so.
“Our family will never recover from what has happened to us. Our mum was absolutely everything to us, she was amazing, and her grandchildren cannot understand that they will never see her again. When the doorbell rings, my youngest child asks ‘Is that nanny?’ It’s completely devastating.”
Margaret’s family are being supported in finding answers from GenesisCare by law firm Slater and Gordon.
Nicole Jackson, associate and clinical negligence specialist, says: “This is an absolutely shocking failure of process which has had the most tragic consequences. Margaret’s family are struggling to comprehend what went wrong, and have to live with the knowledge that had the tumour been acted upon, their mother would most probably still be here with them today.
“There are many questions to answer here, and we will support them in finding the truth. It is vital that we establish how these failings were allowed to occur and what lessons must be learned, to support the family in ensuring this never happens again.”
If you think you or a loved one has experienced medical negligence, we urge you to get in touch with our clinical negligence specialists. Our experts understand the difficulty you have faced, and will be on your side every step of the way. Contact us here.
