Lancashire mum-of-three died after her brain tumour ‘nearly doubled in size’ despite being told it was not growing, investigation finds
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May Ashford was diagnosed with a brain tumour in 2010 at Blackpool Victoria Hospital after experiencing headaches and seizures.
She was transferred to Royal Preston Hospital where she was told her tumour was not growing, despite regular MRI scans showing it was pushing her brain to one side.
When her consultant saw her for the final time in December 2014, her husband Alan, of Warley Road, said he “had a shock”.
He says the meningioma had grown from 2.8cm to around 4.3cm, increasing the possibility of Mrs Ashford being injured or dying following surgery.
Alan said: “Her consultant said if we don’t do something now it will kill her, but she wasn’t operated on until May 2015.
“Eventually she didn’t want the operation because she was convinced that it was too late.
“When you read the full report by the Ombudsman it was really too late by then. She was just left to die over a four-year period.”
Tragically, Mrs Ashford died from a stroke following the 12-hour operation.
“She was dying before my eyes”
The couple married in 1979 before moving to Blackpool to start a family which includes three children, a granddaughter and a one year-old great granddaughter whom Mrs Ashford never got to meet.
Alan, now aged 73, says he initially believed the tumour was not growing and put her symptoms down to the medication she was on.
It was not until after her death that he realised something was wrong.
“When she died I wasn’t pleased with what had gone on. It had sunk in too late,” Alan said.
“I requested all of the medical records and the scan reports, and even as a layperson you could see that the tumour had been growing all of the time.
“I blame myself because I just trusted him [the doctor].”
Alan subsequently brought a complaint to the Parliamentary and Health Service Ombudsman (PHSO) who confirmed his suspicions.
The investigation found Mrs Ashford’s surgery was offered too late as medical staff had “failed to monitor the scan results properly and did not report significant findings”.
Independent medical specialists also told the Ombudsman that Mrs Ashford should have been offered surgery three years earlier.
Alan said: “The tumour should have been removed before it came into contact with the carotid artery.
“The fact that it was not is a complete mystery to us.
“We have no idea why the consultant concerned acted in the way that they did, and as we have never been offered an explanation, we have no closure.”
“My wife suffered horribly from the effects of the tumour for more than four years”
Ombudsman Rob Behrens said Mrs Ashford’s case emphasised the need for urgent improvements to imaging practices in the NHS.
He said: “This tragic case highlights why we have been calling for imaging improvements to be treated as an urgent issue of patient safety.
“Our casework shows that sadly, Mrs Ashford is not the only person who lost her life because of mistakes related to scans and X-rays.
“Timely analysis and reporting of scans is fundamental to the diagnosis and management of many health conditions.
“The sooner we see changes made; the fewer people we will see harmed by these entirely avoidable failings.”
The Ombudsman’s 2021 report on NHS imaging highlighted repeated failings such as those found in Mrs Ashford’s case.
A Lancashire Teaching Hospitals spokesperson said: “As a Trust we acknowledge the findings of the Parliamentary and Health Service Ombudsman report relating to the care of Mrs Ashford and have offered our unreserved apologies to Mr Ashford.
“A detailed action plan was provided to Mr Ashford in November 2022 describing the measures that have taken place following the PHSO investigation to ensure that other patients and their families do not have a similar experience.”
PHSO led a call alongside NHS England and the Royal College of Radiologists to urge the Government to prioritise improvements to the way scans and X-rays are carried out and reported on.
The PHSO says there has been an effort across the NHS to implement the Ombudsman’s recommendations since then but progress has been slow.
Alan said: “Thanks to the Ombudsman’s meticulous report, new rules regarding the monitoring of patients have been implemented by the hospital to ensure that this cannot happen again to anyone else.”