Wrong diagnosis that devastated a family

By JAMES GARDINER

Jean Keefe could fairly be described as a health nut. She did not smoke or drink, she played sport to representative level, ran marathons and took her fitness seriously.

She even worked in health administration, but in the end the health system failed her.

A misread histology slide from a tissue sample taken from a lump in her breast meant she lost a year before she realised she had cancer.

By then it was too late. She had secondaries in her bone marrow and was given only months to live.

In fact, she lasted nearly two years but her battle - without painkillers and chemotherapy, which she shunned - became unwinnable and exacted a terrible toll on her family.

She left daughter Joanne, aged 13, son David, 8, and husband Mike, a former detective who spent hundreds of hours and thousands of dollars trying to find out what went wrong and how to prevent it happening again.

Mr Keefe said the relationship suffered as his wife's health deteriorated and she became desperate to find alternative treatment from people he regarded as frauds.

Even before she was finally correctly diagnosed in May 1993, Mr Keefe had noticed a decline in her health.

She had represented Bay of Plenty at tennis, did aerobics and played netball. But in August 1991 she discovered a lump in her right breast and later visited her doctor, who referred her to a surgeon the following January.

Initial tests were inconclusive - pathologist Dr Ronald Ensor read a cytology smear and pronounced it probably benign, but recommended a biopsy (tissue sample) to confirm that.

The surgeon and Mrs Keefe decided to monitor the situation, with a followup in three months.

In April 1992, a biopsy was taken from the breast lump, which seemed to have grown. Dr Ensor examined the tissues again at Medlab Rotorua and diagnosed hormonal mastopathy, or no cancer.

"It was obviously a relief to her, to both of us," Mr Keefe recalls. "But as time went on she was getting really grotty."

Over the next year Mrs Keefe's life deteriorated. Her energy levels plummeted. Uncharacteristically, she found herself in personal confrontations at work - and at home.

When another pathologist discovered the bone marrow cancer in May 1993, the original breast biopsy slides were reviewed and the mistake was discovered.

Mrs Keefe's mother, Doreen Meihana, believes two lives were lost - Jean's and that of her father, Arthur, who delayed his own kidney treatment as he watched his beloved eldest daughter's demise.

Mrs Meihana recalls the day of her daughter's funeral. Mr Meihana was supposed to stay at home - "he was crook" - but he went anyway. After that he went to Waikato Hospital and began getting the dialysis he needed, but died at home, aged 70, two months after his daughter.

"He was so proud of his eight kids, but there was something special I think between Jean and her father."

Dr Ensor told the Herald he believed that both Mrs Keefe and another patient whose slides he also misread would have died, even if he had got it right. "[Mrs Keefe] would have survived a little longer if she accepted chemotherapy."

But in writing up the Medical Practitioners' Disciplinary Committee finding against Dr Ensor, chairman Dr Dean Williams said: "Whilst it will never be known whether earlier intervention would have extended Mrs Keefe's life, it is nevertheless true that earlier intervention would undoubtedly have offered a better opportunity to have achieved that result."

Mr Keefe is convinced that earlier recognition and treatment of the cancer was the only chance his wife had. He said she lost faith in the health system when Dr Ensor's mistake was discovered.

Given just a few months to live, she decided to seek out alternative forms of treatment.

Mr Keefe decided to mount his own investigation.

"I started writing letters to various people in the medical profession. I adopted what you might call a shotgun approach. I wanted to shake the bushes and see what would fall out of the tree.

"I thought I was in a position where I could possibly force an audit. Partly, it was to try to help someone else if another mistake had been made, whether by this guy or somebody else.

"And I know that part of the local medical profession here was also very keen that some audit was done, that something was done to have a look to see no other mistakes were made. Other parts sort of wanted me to go away."

His letters included a request to Medlab Rotorua that any files, slides or tissue samples be returned to the family.

He said Medlab told him it had nothing on file, that everything had been sent to the ACC.

But the ACC told him all it had were two slides, which it sent him. When he had those examined by a pathologist, they showed no signs of cancer.

Three months after Mrs Keefe's death, Medlab director Dr David Taylor contacted her husband and asked him to come in to see him.

"I wasn't really wanting to talk to him, but I smelled a rat and it was just unusual for him to want a meeting with me and I went there feeling that he wanted to try and talk me out of taking some sort of action."

Mr Keefe and Jean's brother Bart Meihana went to Medlab in Amohia St and both secretly taped the meeting.

The tapes were to prove useful at the Medical Practitioners Disciplinary Committee inquiry when a lawyer acting for Dr Ensor, citing an affidavit from Dr Taylor, said Mr Keefe had blamed Dr Ensor for his wife's death and said he wanted him put in prison.

The transcripts show he said no such thing.

Dr Taylor began by telling Mr Keefe and Mr Meihana that the tissue samples had been disposed of "with appropriate decorum through the hospital disposal system."

He said that was common practice after four to six weeks "if there's no claim," although no records were kept of the disposal.

He denied that he had taken further sections off the tissue block to make new slides, saying his review of Dr Ensor's misdiagnosis had been based on checking the slide or slides that Dr Ensor would have viewed originally.

When Mr Keefe pointed out that Dr Ensor had previously told him the tissue block had been sent to the ACC, Dr Taylor left the room and returned with laboratory assistant Lyndal Walker.

She confirmed that Medlab no longer had a tissue block from Mrs Keefe's biopsy, then, when asked by Dr Taylor where it went, said: "I presume it was all cut out when you made those slides."

Mrs Walker suggested that the block might have been sent with the slides to ACC. She thought she might have packaged it up to send, but was not sure.

Dr Taylor then asked Mrs Walker to search for the tissue block, checking under different names such as O'Keefe.

He said that even if a tissue block was "cut out," the paraffin it was embedded in would be retained - "We don't throw them away do we?"

Mrs Walker: "Yes, sometimes we do."

Dr Taylor had also revealed that Medlab still had one "file" slide, which it had placed with lawyers.

He explained that the reason he had asked for the meeting was that Mr Keefe had been writing "long-winded" letters to the hospital and to other pathologists about the case and he wanted "to eyeball you, like we're doing now."

Later, Mrs Walker returned to the meeting with another staff member, Christine Thom, who said she remembered the slides and tissue blocks sitting on a workbench and Mrs Walker asking Dr Ensor what should be sent.

"And he said, 'Send the lot,' and that was the blocks - and they went. I'm sure they went," Mrs Thom is heard on the tapes saying.

But even then, Mrs Walker repeated that she could not remember exactly what she sent.

Mr Keefe recalls that Dr Taylor, who had seemed nervous and ill-prepared throughout the meeting, was anxious not to allow him to question either woman directly.

Later, while at work at the police station, Mr Keefe received a call from a woman who did not identify herself but said he would not find the tissue samples because they had been destroyed. He traced the call to a phone box.

When the Herald approached Mrs Walker, she denied there was any coverup or any destruction of tissue samples or slides.

Five years on, she also seemed to have regained her memory of what happened: "We sent everything we had down to Wellington."

She denied she had called Mr Keefe. "Nobody at the lab would do that. The only people concerned with that case were Dr Ensor, Dr Taylor, Christine and I. Nobody outside our lab would have even known about that case."

Mrs Thom refused to discuss the matter until she had taken advice from the new directors of what is now Diagnostic Rotorua.

The next day, both she and Mrs Walker said they had nothing to add and referred inquiries to director and part-owner Dr Ian Taylor, of Tauranga, brother of Dr David Taylor, who has now retired and sold his stake in the business.

Dr Ian Taylor did not return the Herald's call.

Dr Ensor was unable to clarify what happened to the tissue sample.

He said that once a tissue sample was taken, dozens and theoretically hundreds of slides could be taken from it, which he likened to a photographic negative - "Take two photographs, they'll be the same."

But they were not the same.

Two slides sent to ACC showed no signs of cancer. Dr Ensor told the disciplinary inquiry he thought they would have showed cancer.

He also told the inquiry he thought both the slides and tissue samples had been sent to ACC, at ACC's request.

He changed his story when the Herald asked him what happened to the tissue block, saying it would have been retained by the laboratory and was possibly "cut out by cutting more and more sections all the time to send hither and yon."

But why was that necessary? If the original slide or slides that he had looked at, and mistakenly failed to detect cancer on, were subsequently reviewed by other pathologists and himself, all realising the error, surely that slide or slides should have been all that was needed to determine whether he had made a mistake and how serious it was.

Dr Ensor's answer was that "people kept asking for copies."

One of those was retired Auckland pathologist Dr George Hitchcock, whom the inquiry called as an expert witness.

His evidence, based on his review of a slide taken from Mrs Keefe's tissue sample, appears to have been crucial to the committee's finding that Dr Ensor's error was at the lower end of the scale.

"I do not find it surprising that a generally trained pathologist such as Dr Ensor should have misdiagnosed this slide," he told the inquiry.

He said he could see why a misdiagnosis was made.

He had had difficulty with the case and referred it to a colleague, who also had considerable experience in breast biopsy examinations.

Together they studied it for 15 to 20 minutes and eventually concluded that malignant cells were present.

But that was also with the benefit of hindsight - "knowing that the patient had subsequently developed metastatic disease in the bone and knowing the patient had subsequently developed breast cancer."

Evidence was also given to the inquiry by another pathologist, Dr Jonathan Allin, who had discovered the bone marrow cancer and reviewed a slide or slides (he thought he could remember two) held in the Medlab files from the 1992 breast biopsy. He said he had no difficulty detecting cancer.

Dr Ensor also did pathology work for Rotorua Hospital. Mr Keefe told the Weekend Herald that he wrote about his concerns to Leith Comer, chairman of the hospital operator, Lakeland Health.

Mr Comer and later a lawyer acting for Lakeland subsequently told him that there had been some checks done and several serious errors had been found.

Mr Keefe does not recall the exact number, nor does he know whether it was considered an acceptable error rate by the authorities, but he does recall being surprised that the audit involved rechecking relatively small batches of slides taken at intervals.

The Weekend Herald asked Rotorua Hospital whether it had conducted an audit of pathology as a result of Mr Keefe's complaint.

It took Rotorua Hospital spokeswoman Juliet Spence five days - and two reminders - to respond to the Herald's inquiry, and it was hardly worth the wait.

"We have no comment to make because if a complaint about another organisation was received by Lakeland it would be passed on to that organisation directly."

Was that what happened? Mrs Spence said she could not elaborate and had "no idea" whether an audit was conducted.

But a letter dated November 1, 1994, from Mr Comer to Mr Keefe confirmed that audits of "selected histology and cytology file slides" were conducted by two Auckland pathologists.

Eight months later, in June 1995, Mr Comer declined to provide the results of those checks, saying: "The outcome was very satisfactory but I have been advised that the report and findings represent privileged information."