Cancer treatment review finds 'betrayal of trust'

Brain cancer patients were routinely given extended, non‑standard courses of chemotherapy, with some being misdiagnosed and exposed to serious risks and harm, a review has found.

The Royal College of Physicians (RCP) is investigating 20 cases in which patients in Coventry were prescribed the drug temozolomide (TMZ) for long periods with "little or no evidence of benefit," it said.

Preliminary findings of the review, leaked to the BBC, said staff failings amounted to a "betrayal of patient trust".

University Hospitals Coventry and Warwickshire (UHCW) NHS Trust said measures had been put in place "to ensure more robust oversight of the prescription and use of TMZ and ensure patient safety".

Stephen Bown from Atherstone, whose son David was prescribed the treatment for eight years, described the review's findings as "incredibly disturbing".

He said his son's health was quickly deteriorating, and believes the treatment he received following a brain tumour operation at the city's University Hospital led to irreversible neurological damage, liver problems and muscle pain.

"The words they are using are damning of the whole system at Coventry," he said.

"People knew that what was going on was wrong," he added.

He is one of more than 40 patients represented by lawyers who say they received TMZ for far longer then recommended.

Of the 20 cases reviewed by the RCP, 15 were judged "unsatisfactory overall", meaning care was found to be well below expected standards.

Four were rated as requiring improvements in both clinical and organisational care, while one needed improvement in clinical care alone.

No cases were judged to represent good practice.

There was "scant evidence" of the understanding and documentation of the risks of taking the drug, the review team found.

Guidelines say TMZ should usually be taken post radiotherapy for six cycles, usually over six months.

But many patients have told the BBC they received it for many years – in one case 16 – and believe they suffered physical and emotional harm as a result.

There are a wide range of side effects associated with the drug, including muscle weakness, memory issues and, in rare cases, secondary cancers and liver damage.

According to the report, in one case, a patient received more than 100 cycles of TMZ before doctors identified that they had a different, less aggressive type of tumour than originally believed.

The patient later developed acute myeloid leukaemia, a serious blood cancer, after showing signs of bone marrow suppression.

The report said there was "insufficient clinical curiosity" in some cases and a lack of collaboration with multidisciplinary team colleagues, allowing potential diagnostic errors to persist.

The report was "damning" and showed "all levels of oversight failing" at the trust, said Becky Addison of law firm Brabners.

The interim report was sent to the chief medical officer of the NHS trust in April, and has only now been seen by patients, their legal representatives and the BBC.

It was "extremely disappointing" added solicitor apprentice Addison.

"Patients have had so much of their lives taken away from and they deserve answers, and there's still so many more answers that they are yet to be given," she added.

"Personally, I would like the two people at the centre of this report criminally prosecuted," added Bown.

The consultant at the centre of the investigation, referred to as Dr Y but who the BBC understands to be retired consultant Prof Ian Brown, did not participate in the review and failed to attend an interview with investigators.

The review team said it received little information about his clinical outcomes or workload and was unable to explore concerns directly with him.

Former colleagues described Dr Y as difficult to contact and resistant to challenge," the review states.

Investigators heard emails often went unanswered and colleagues frequently struggled to obtain responses about patient care.

The review team also said he avoided many of the professional and managerial demands expected of him.

It said he did not attend departmental meetings and developed a backlog of patient mortality reviews.

The report also criticises a former clinical nurse specialist - Mr N - describing his working relationship with Dr Y as "very unusual".

It said care for the patients was primarily managed and delivered by Mr N, with Dr Y having very limited direct involvement.

The review team considered that Mr N practiced outside of recognised standards, specifically in relation to his:

• Failure to ensure that information and advice given to patients was accurate and evidence-based
• Failure to ensure properly informed consent and to document it
• Delivery of individualised, patient-centred care, including respecting and supporting patients' right to accept or refuse care and treatment
• Standard of clinical record keeping
• Level of accountability for his actions and in particular his practice as a non-medical prescriber

The report also questioned why oncology pharmacy teams did not challenge patients receiving oral chemotherapy continuously for 10 to 15 years.

"There were multiple opportunities for scrutiny and challenge," the review found.

"Dr Y appears to have been a difficult individual to engage with, but multiple opportunities for scrutiny and challenge were missed," it added.

Criticising the pharmacy team for failing to raise concerns it said: "Senior pharmacists should have recognised the use of an oral cytotoxic drug for 10-15 years was very unusual… no consideration was given by the pharmacy team to the evidence behind the need for this prolonged temozolomide treatment."

It said: "A lack of awareness of this non-standard prescribing as a defence for inaction was hardly credible."

"I think the most shocking part is everyone knew," added Addison.

"Everyone knew and they didn't speak out.

"They didn't protect patients' interest and they allowed this to happen," she added.

The letter said while progress had been made in the oncology department and pharmacy service, "there was still much work to do to ensure appropriate oversight and to prevent a repetition of the concerns identified."

It said the arrangements remained too reliant on staff self-reporting issues, and the governance of non-medical prescribing was a particular area of weakness requiring "significant improvement."

It made recommendations including independent reviews of all living patients' cases and for the trust to consider whether Mr N should be referred again to the Nursing and Midwifery Council. A previous referral concluded there was no case to answer.

A UHCW spokesperson said all patients receiving TMZ at the time of Dr Y's retirement in 2025 had been reviewed by senior clinicians, "with appropriate care plans put in place".

"We are also undertaking an independent review of our speak up processes, led by an independent party, to ensure staff feel fully supported and confident in raising any concerns.

"The trust will assess the full RCP review when it is published and will take further appropriate action based on its findings.

"We want to reassure our community that patient safety, experience and wellbeing remain our top priorities," the trust added.

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