An 84-year-old man, Alan Soane, died in June 2023 from complications of a high-risk surgery to remove a rare form of cancer that he did not have. The misdiagnosis was made after an endoscopy and biopsy of Mr. Soane’s small intestine at a local hospital in Essex, which concluded that he likely had a type of cancer that grows in glands that line the organ. Further tests were not conducted to confirm the diagnosis. Mr. Soane was referred to the Royal London Hospital, where doctors diagnosed him with cancer of the duodenum based on an immunohistochemical test. However, they did not perform any further biopsy tests to confirm this diagnosis. As a result, Mr. Soane underwent a complex and risky Whipple procedure, which carries a 10% chance of dying during or after surgery and a 5% chance of surviving up to five years, even if successful. Mr. Soane died on June 26 as a direct result of complications from the surgery.
A Prevention of Future Deaths report issued by the coroner for Inner North London raised concerns that the Royal London Hospital did not have a consultant histopathologist to help doctors. Histopathologists study organs, tissues, cells, and genetics to help provide a diagnosis. The report also noted that the issue of a shortage of consultant histopathologists had been on the Trust’s risk register for over five years, with 25% of such roles vacant nationally. The coroner expressed concern that the national shortage of consultant histopathologists puts a widespread proportion of the patient population at a significant risk.
Duodenal cancer is a tumour in the first portion of your small intestine, which receives food from your stomach during digestion. It can prevent the intestine from properly digesting food and even block food from passing through. For this reason, symptoms can include:
* Abdominal pain
* Weight loss
* Nausea and vomiting
* Diarrhoea or constipation
* Fatigue
* Blood in your stools
But many people won’t notice any signs in the early stages of the disease.
Duodenal cancer is rare, making up less than 0.5% of gastrointestinal cancer cases. There is no figure for the number of people affected by duodenal cancer every year in the UK, but there are about 1,800 small intestine cancer cases and 555 deaths annually. Anyone can develop duodenal cancer, but men aged 60 to 80 with other intestinal conditions like coeliac disease and Crohn’s disease are thought to be at increased risk.
