A damning report has revealed how hospital chiefs in Cornwall missed an opportunity five years ago to tackle a consultant obstetrician now at the centre of an inquiry over care.
The report, following a review into consultant obstetrician Kenneth Jones by the Royal College of Obstetricians and Gynaecologists (RCOG), lifts the lid on how The Royal Cornwall Hospital at Treliske, Truro (RCHT) "disappointingly" failed to deal with mounting concerns about him.
Worries had been spiralling from both staff and patients since 2007 and yet RCHT only acted last year by asking the RCOG to review the situation.
The report stated: "We are disappointed with how the trust has managed this situation.
"There was a clear opportunity in 2007 to deal with a number of the issues and consider referral to NCAS or retraining."
NCAS is the National Clinical Assessment Service that aims to improve patient safety by helping to resolve concerns about the practice of doctors, dentists and pharmacists in the UK.
The RCOG found RCHT's own audit into the matter had not been adequately used to identify – or exclude – a problem with Mr Jones.
Some 1,574 women the medic treated over the last two-and-half years have now been contacted by RCHT.
Mr Jones took up his post in 1992 and was clinical director from 1997-2001.
From 2007-11 he chaired the guidelines group.
The review was to later find he did not closely follow guidelines laid down for colposcopy and obstetrics.
Mr Jones stopped operating in November last year and left the hospital in May – he is now retired.
When RCOG officials went into RCHT in January this year, they spent four days wading through medical records and interviewing staff.
They found Mr Jones made "bizarre" decisions, was difficult to challenge and there were major concerns about his colposcopy practice over some years, leading to him stopping doing the procedure in 2011 – had also not followed guidelines surrounding the practice.
Concerns over possible bullying were raised and Mr Jones was found to carry out poor documentation and communicate poorly.
There was also little, if any, documentation of risk recorded on consent forms patients signed prior to surgery.
The RCOG said it gained an "impression of increased surgical complications" following surgical procedures.
"Appalling" relations with some staff was found – two of whom were consultants who both ended up in tears.
It was also revealed Mr Jones would be accompanied and "managed" by midwives on his ward rounds to make sure "an optimal outcome" was achieved, with registrars asking to "do one thing in the knowledge that he will choose the opposite".
Staff also said while he could make good decisions he was not always consistent.
The report found there was an initial investigation in March 2007 by the hospital of seven women with high-grade cervical cytological abnormalities.
The review read: "It is difficult to ascertain what the outcome of the review was, but it is suggested that [Mr Jones] was not following national guidelines with regard to treatment and recall for these young women."
However, inspectors found Mr Jones was described "almost unanimously as a very nice person" who had been very supportive of his staff and was said by some members of staff to be "the social cement of the department" and was "very sensitive and looks out for people".
When asked about his strengths, members of staff said Mr Jones always read the notes before seeing a patient, they had learned a lot from him and had enjoyed working with him.
In a statement Lezli Boswell, chief executive at RCHT, said: "We acknowledge the RCOG report identifies some concerns about the trust's historic management of the case.
"This is exactly why we have commissioned the external review to learn any lessons for the organisation, and possibly the wider NHS. We expect the independent external review to be completed by the end of this calendar year."
