RCP Review Finds "Betrayal of Trust" in Prolonged Temozolomide Prescribing at Coventry NHS Trust
核心洞察
A Royal College of Physicians (搜索) review of 20 brain cancer cases at University Hospitals Coventry and Warwickshire found prolonged, non-standard temozolomide courses with little or no evidence of benefit.
Fifteen of the 20 reviewed cases were judged unsatisfactory overall, with no cases rated as representing good practice, according to leaked preliminary findings.
One patient received more than 100 cycles of temozolomide before doctors identified a different, less aggressive tumour, later developing acute myeloid leukaemia (搜索).
Brain cancer patients at a Coventry hospital were routinely prescribed extended, non-standard courses of the chemotherapy drug temozolomide (TMZ), with some misdiagnosed and exposed to serious harm, according to preliminary findings of a review by the Royal College of Physicians (搜索) (RCP).
The review is investigating 20 cases at University Hospitals Coventry and Warwickshire (UHCW) NHS Trust in which patients were prescribed TMZ for long periods with "little or no evidence of benefit." The leaked preliminary findings, seen by the BBC, concluded that staff failings amounted to a "betrayal of patient trust."
Of the 20 cases reviewed, 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.
Deviation From Standard Dosing
Guidelines state that TMZ should usually be taken post-radiotherapy for six cycles, typically over six months. However, many patients have told the BBC they received the drug for many years — in one case, 16 years — and believe they suffered physical and emotional harm as a result.
The review team found "scant evidence" of the understanding and documentation of the risks of taking the drug. TMZ carries a wide range of side effects, including muscle weakness, memory issues and, in rare cases, secondary cancers and liver damage.
In one case described in the report, 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 (搜索), a serious blood cancer, after showing signs of bone marrow suppression.
The report cited "insufficient clinical curiosity" in some cases and a lack of collaboration with multidisciplinary team colleagues, allowing potential diagnostic errors to persist.
Oversight Failures Across the System
The review 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, adding that "Dr Y appears to have been a difficult individual to engage with, but multiple opportunities for scrutiny and challenge were missed."
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 added: "A lack of awareness of this non-standard prescribing as a defence for inaction was hardly credible."
The consultant at the centre of the investigation, referred to as Dr Y and understood by the BBC 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," with emails often going unanswered and colleagues frequently struggling to obtain responses about patient care.
The review team also said he avoided many of the professional and managerial demands expected of him, did not attend departmental meetings and developed a backlog of patient mortality reviews.
The report additionally criticises a former clinical nurse specialist — Mr N — describing his working relationship with Dr Y as "very unusual." 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 practised outside recognised standards, specifically in relation to his failure to ensure 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 patients' right to accept or refuse treatment; standard of clinical record keeping; and level of accountability for his actions, particularly his practice as a non-medical prescriber.
Patient Cases and Legal Action
Becky Jones was 21 when she was told she had a terminal brain tumour (搜索) and months to live. The diagnosis, made by an experienced cancer consultant, led to 11 years of chemotherapy that she says changed her life — causing regular nausea, curtailing her career and preventing her from taking part in family events. Now 33, she recently learned she never had cancer at all, but rather a tumefactive demyelination (搜索) — an inflammation of the brain that could have been treated with steroids.
"I was told time and time again without the chemotherapy I would die," she said. "I never had a brain tumour (搜索). I was misdiagnosed and I've gone through all this treatment for the main part of my adult life, for no reason."
Fiona Tinsley, a partner at law firm Brabners (搜索), said Prof Brown had diagnosed Jones with a grade four glioblastoma (搜索), one of the most aggressive forms of brain cancer, before the biopsy results had returned. Jones was told she would need TMZ for the rest of her life, despite guidelines recommending six cycles over six months. When she questioned multiple scans that did not appear to show evidence of a tumour, she says the consultant told her it would not be "visible to the naked eye."
Jones described her years on chemotherapy as "horrendous," citing constant nausea, stomach pains, mouth ulcers and day-to-day fatigue. Her driving licence was initially taken away and then restricted, and she and her partner were told she would be unable to get pregnant. "I later went on to have two children, which he told me were both miracles," she said.
Her treatment continued until 2024, when she received a phone call from a doctor saying her chemotherapy was stopping. "He didn't have any reason as to why. He told me Ian Brown had retired — this was the first I'd heard of it," Jones said. In May 2025, after independent analysis by neurosurgeons and radiologists on behalf of her lawyers, she was told she had never had brain cancer at all.
Jones is one of more than 40 patients represented by lawyers who say they received TMZ for far longer than recommended. One patient said she believed the drug had made her infertile, while another developed leukaemia after 100 unnecessary cycles.
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 (搜索) operation at 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."
Becky Addison of law firm Brabners (搜索) said the report was "damning" and showed "all levels of oversight failing" at the trust. "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 said. Bown added: "Personally, I would like the two people at the centre of this report criminally prosecuted."
Trust Response
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.
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." The trust said measures had been put in place "to ensure more robust oversight of the prescription and use of TMZ and ensure patient safety."
"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 spokesperson said. "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 letter accompanying the findings said that 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."