13th May 2001
 

SIN has been working tirelessly on Anne's case for the last twelve months. SIN has written dozens and dozens of letters alerting people in authority, who are paid to protect the patient, of the  desperate plight of this seriously ill  patient. We shall in the near future be giving a summary of these letters. SIN has alerted her MP, the Health Authroity, the Regional Office , CHI and  Mr Alan Milburn's Office  about Anne's predicament - all to no avail!!

Anne's case is very important, not only because she is so very ill and we believe her life to be at risk, but also because over the last 12 months major initiatives and statements have been issued by Mr Alan Milburn from Richmond House which have been put in place for the protection of the patient. SIN is in a position to state quite categorically that

Up until October last year we had been willing to support Anne in a full reassessment  of her condition with the consideration of non-obstructive intestinal cancer being uppermost in our minds. We were finding it impossible to get any hospital in London to admit her for reassessment in spite of her changing symptoms  and worsening condition. The Chief Executive of the Health Authority had sent us a letter  dated 19th June,2000  with a concluding sentence:

So much for health professionals, Health Authorities  and Trusts  being instructed by the D.0.H to work with patient support groups!! Anyway SIN was undeterred and continued to fax the HA and to communicate with the Regional Office and Anne's GP.

On 13th October 2000  SIN faxed Anne's GP  requesting copies of recent blood tests and   summaries of consultations, Anne having a right to these. Anne had given SIN her written authority to act on her behalf, and this had been faxed through to the surgery. The GP was also informed in writing of how desperately ill she was. SIN was told by the receptionist to telephone at a given time for a discussion with the GP. SIN kept to the allocated time but was curtly told by the Practice Manager that the GP would be taking no  telephone calls nor answering any faxes!! A dead end here!

• Anne had had TB of the hip in her youth ( 16yrs) and was hospitalised for 4 months bed rest under the care of a TB specialist, with painful  daily injections of antibiotics into her hip.
• Anne had been feeling ill and tired before she went on holiday in the summer of 1996.
• Anne had been nursing TB infectious patients.
• When Anne returned from holidays she developed a terrible cough with sputum, abdominal pains and a loss of appetite. Her weight dropped by over 2 stones in one month. If anyone has seen the photo of how slim  Anne was in the summer of 1996, then a loss of so much weight left her looking like a skeleton
• Anne was given many antibiotics by her GP, but nothing cleared the cough.
• She was admitted to the local hospital for 6 weeks in a room of her own.
• Anne asked if she could have a skin test for TB  - it was very positive.
• Anne was put under the care of a chest specialist and underwent many tests. 
• She was shown an X-ray of her chest with large white patches on both lungs - she asked if this was cancer. She was told it was not cancer.
• She asked if she had TB , she was  given an  evasive answer and told that the doctors were waiting for the results of all the tests.
• She consumed a great amount of antibiotics

With the help of Anne's friends and the internet we began to research abdominal TB and found that Anne's symptoms were an exact match!!  Could Anne have been suffering from TB of the Gastro-Intestinal Tract and Peritoneum for over 4 years?

SIN decided to raise this matter of TB with her GP and the HA doctor. A fax was sent dated 31st. October requesting a meeting with the GP and the HA doctor to discuss this issue. A very encouraging response was received. A meeting was arranged wiht Anne,her GP,SIN as patient advocates and the HA doctor.

The GP went through all the tests  Anne had taken in 1996 and when questioned confirmed that  these were tests for TB and she  had been a suspected case. Anne's early history of TB was also discussed. SIN read out all Anne's symptoms and asked Anne to verify them. SIN asked the HA doctor if these were symptoms of TB of the GI tract & peritoneum, he confirmed they were and suggested that Anne had a "low grade TB infection". The meeting  ended in a very amicable manner and SIN was really hopeful that Anne would soon be receiving the care and treatment she so badly needed. SIN requested, on Anne's behalf,  all copies of the tests relating to 1996. The GP promised them within 24 hours. Anne & SIN are still waiting .

                                     These were Anne's symptoms on the 24th November, 2000

• Severe abdominal pain
• Abdominal tenderness

• Palpable mass (?)
• Swollen abdomen ( full of fluid - ascites?)
• Desperate feeling of ill health
• Diarrhoea
• Nausea
• Pain in back
• Intermittent bleeding ( the HA doctor had suggested that she had small ulcers - ulcerations of the ileum are a frequent feature of TB)
• Breathlessness
• Polycystic kidneys - feature of tuberculous peritonitis
• Fat in her stools - pancreatic involvement?
• Abnormal liver function tests - hepatic involvement?

After 2 weeks had passed  SIN was concerned that Anne had not received any tests for TB which should surely have been obligatory after the meeting. On  medical  advice Anne should have had 3 simple inexpensive tests:

•  Tuberculous Skin Test ( TST)(Mantoux test)
•  ZN test -  TB culture
• PCR - which is a DNA test for TB using fluid extracted from the abdomen

" ... decreased attenuation compatible with diffused fat replacement, most marked in the right lobe"

From medical advice SIN  believes that this indicates TB of the liver and was a very serious condition. The summary of the consultation eventually arrived. No mention of TB, no mention of being admitted to the hospital for tests. Anne was distraught since it was nearing the end of February. She discovered that the consultant was away on holiday.

Friends of Anne, and members of SIN, e-mailed the hospital to express their concern at the poor standard of medical care she had received. The Medical Director contacted them very quickly and once he heard Anne's medical background he assure them that : " we always put the patient first and because she has been opened up so many times, rather than do a liver biopsy they would do other tests  first to determine where the TB is..." he also said he would speak with the consultant when he returned to work. The following Friday evening the consultant telephoned Anne at home and profusely apologised and promised he would get her admitted as soon as possible.

 SIN faxed the Medical Director on 5th March expressing our concerns.In this letter we documented the details of her relevant past medical history set out above, the contents of the November meeting and a list of her symtoms and scan result. The penultimate paragraph reads:

"SIN is shocked that nearly four months after the November meeting took place when Anne and  SIN were assured that urgent action would be taken to address her health concerns, Anne has yet to receive tests for TB and specialist care. SIN reiterates that this lady is desperately ill and is in urgent need of specialist care without delay. We hope she can be admitted to the Trust for a thorough reappraisal as soon as possible and that all her health concerns can be addressed in a sympathetic, respectful and friendly atmosphere."

The last para. requested a meeting wiht the Trust, Anne and SIN as patient advocates. This request has been submitted several times since to the Trust, but it has always been ignored! The Trust has never had the courtesy to respond.

By a lucky chance Gillian & Margaret were in London on 13th March and were able to visit Anne. A photograph was taken of her swollen abdomen. Click here to see a recent photo. Anne had been admitted to a Ward specialising in infectious diseases of the GI Tract.  A notice on the room next to hers was in red and said " Barrier Nursing". On the ward notice boards the staff were reminded that all strains of TB should be reported to the Public Health Laboratory and there was a reminder of a seminar on " Aids and TB". It seemed that Anne was in the right place to be tested for TB and to obtain the correct treatment. There was also a Public Health Laboratory a few yards down the corridor from the Ward.

Curiously, whenever Anne asked if she were being tested for TB, the doctors replied that  she was not being tested for TB because she did not have TB!! The logic of which escapes us! She did have  an endoscopy  and a colonoscopy with biopsies of the ileum and colon. SIN telephoned the ward, on Thursday 15th March, about 8.30pm to ask how Anne was after these tests. The nurse said she was still unconscious and recovering with the help of oxygen.

SIn made sure that the Chief Executive who was a medical doctor had copies of all our correspondent sent to the Medical Director. A Fax went in on 21st. March:

"As a medical doctor yourself, Chief Executive, you will be fully aware of the significance of Anne's present symptoms and her past history of TB infection and recent contact with infectious TB  patients, all of which is clearly set out in the above correspondence.
SIN .....does not wish to extend written communication which seems to proliferate "misunderstandings"; rather SIN , as patient advocates, requests a face to face meeting with the parties involved including Anne , Dr....... the Medical Director and yourself."  A second request for a meeting - ignored.

By now SIN was very concerned that a basic TST (Tuberculin Skin Test) had not been done,  four months after the November meeting. Why had not a TST been done on Monday 12th March when Anne went into the London hospital? In our opinion this was very  puzzling Clinical Governance!

On March 23rd. SIN sent in a fax to the Medical Director ( copy to the Chief Executive)  headed:

"Is the Trust refusing to test Anne for TB? Not to do so would, we believe, be a criminal matter".

Anne was given a Mantoux ( TST) on  Thursday, 29th March.Why had it taken over two weeks for this standard test to be done? Surely such a test should have been done within the first 24 hrs?

The TST should be measured after 48 or 72 hours., and it is the swelling or induration which should be measured with a flexible ruler.  The measurement is in mms and usually 5mms to 10 mms is sufficient for a positive test. Anne's test came up very positive. By another lucky chance Margaret & Gillian were in London on Monday 2nd April and were able to visit Anne and took a photograph of the skin test.  This was 4 days after the test and the induration measured 9 X 6 cms  - 90mm to 60 mms.  The previous day, Sunday,  72 hours afterward the test had been performed,  Anne's arm was so swollen that she had difficulty in pulling her pyjama sleeve over the swelling. By any standard this was a massively positive test. She had also started to have fevers again.  Click here to see a photo of Anne's arm .

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June 4th 2001: Questions Arising From the Mantoux Test

Why was the  TST  given on a Thursday when it was known that  it would  require measuring over the weekend? By Saturday evening ,48 hrs after the TST had been done, no one had been  to measure it, so Anne had to request a nurse to fetch a doctor.  The doctor who came took a measurement, decided that it was positive and tried, unsuccessfully, to   contact a micro bacteriologist.   (Recently SIN has been informed that a micro-bacteriologist  is  on 24hr call, and since the Ward had a Public Health Laboratory there should have been no difficulty in obtaining  one). A micro-bacteriologist is required to identify the exact strains of TB which are present. Next, the doctor contacted a more senior colleague to seek advice as to whether Anne should be isolated. The doctor was told that because of Anne's symptoms she was considered to have abdominal TB and, therefore, since it was not pulmonary TB she was not thought to be  infectious and  isolation would not be necessary. Anne left a Voice Mail on Satruday evening informing SIN that a doctor had confirmed that the TST was positive for tuberculosis infection.

As described above, Gillian & Margaret visited Anne 4 days after the TST was done, and  Anne's arm was still very swollen. Whilst they were there, the TB (Chest) Specialist came at about 4.30pm to measure the TST and pronounced it positive. It was thought that at last Anne would get her written diagnosis and treatment, after all, we now had four doctors who had  confirmed that Anne had TB, two of them identifying abdominal TB. This, however, turned out to be very premature. The consultant gastro-enterologist  did not see Anne for several days. One Registrar said that this Consultant thought she had TB "somewhere" in her system! ( The abdomen might be a good starting place?) 

Anne was kept in the Ward for a further  two weeks, during this time she had two X-rays taken, one of her chest and one of her pelvis. She hardly saw a doctor during this period.

With such a positive TST why was Anne not immediately referred to a TB specialist? This, we understand would be the normal protocol. If it were necessary for Anne to see a micro-bacteriologist on Saturday, 31st. March, why did Anne eventually leave the Trust on Friday 13th April without having been under the care of either?
Again, big questions about Clinical Governance. Sin brought these concerns, quite properly,  to the attention of the Medical Director who was then absent for two weeks. SIN was told that the Assistant Medical Director, in charge of Clinical Governance, would be dealing with the correspondence. Two letters were faxed to the Trust one dated 31st March  and the other dated 9th April Both letters dealt with  similar points and the following are extracts from these letters:

"SIN is delighted that the clinicians at the Trust have solved the problem of Anne's long term ill health and have now agreed on the diagnosis of Tuberculosis of the abdomen. She has been told that she will be given anti tuberculin drugs shortly" (both letters)) 
Request for micro-bacteriologist:
"From information received from WHO ( World Health Organisation) anyone who becomes re-infected with the disease (eg Anne) is likely to experience the mutation of the bacteria into more resistance strains and......will require extra strong antituberculin drugs. Only a micro-bacteriologist is able to identify the individual strains and the correct tuberculin drugs which should be prescribed. Therefore, we request that a micro-bacteriologist sees Anne as soon as possible. It is also essential that both  the TB consultant and the micro-bacteriologist have all the past relevant  history of Anne's previous TB infections and their source. We consider this to be a matter of Clinical Governance".( both letters).

Confirmation requested of  which TB tests had been undertaken, and their results
In a letter dated 30th March, the Medical Director wrote: " ...I would ask you to be more specific as to which test it is that you believe that we should be undertaking...."
SIN requested answers to the following question in a letter dated  9th April:
"We did request 3 simple inexpensive TB tests in our fax of 23rd. March. One of these,the TST, was done 6 days later on 29th March ( very positive). .....we ask now for information that Anne has had the following two non-invasive tests:
ZN TB culture test
PCR test for TB testing of DNA of her abdominal fluid.

Sin went on  that from information received, two other, more invasive tests could be done:
(i) Laparoscopy - which reveals a rash of miliary TB on the peritoneum & TB adhesions.
(ii) Liver biopsy. However, SIN reminded the Medical Director that he had said that all other tests for TB would be carried out first before attempting a liver biopsy, which presumably had more inherent risks. SIN simply wished to verify what tests had been done and the results.

"Public Health Issue: the extent of Anne's infectivity (SIN referred to the TB outbreak in Leicester):
"...on April 2nd, Anne looked very unwell, she felt very ill and she was sweating profusely. We are now very concerned as to the risk of infection from Anne and wish to know as a  matter of urgency how infectious Anne is and the particular strain of TB which is causing her illness." ( Letter 9th April)

.....(After the November meeting, SIN had contacted Anne's GP with the same question. He had replied that provided a contact had an up to date BCG vaccination, there would be no risk!!!)

Clinical Governance: SIN was surprised to receive two letter from the Director of Clinical Governance - one in response to our letter dated 31st. March  ( which was why we sent in the second  letter  & )one in reference to our letter dated 9th April. In both he stated:

".....Again, I cannot reply directly to the questions unless Anne asks us to...."

This puzzled us greatly for two reasons. Firstly, Clinical Governance, to the Labour Government's credit, has been introduced into our hospitals as a way of improving clinical standards of care and giving the vulnerable patient greater protection. SIN assumes that all the posts of Clinical Director, which have been recently approved in the Trusts, carry with them an adequate remuneration paid by the tax-payer, and specific responsibilities of "supervising" and "surveillance" of clinicians within the Trust. Sin had therefore, assumed that the Director of Clinical Governance would have had a personal responsibility to investigate any matters brought to his attention which suggested  problems of Clinical Governance within the hospital. Surely, it is  not appropriate to get permission of the patient? Imagine how intimidating this would be if the patient had to sanction such an investigation. SIN understood that the Director of Clinical Governance would be assuming responsibility himself for any necessary   investigation.

The second reason why this statement puzzled us was that the Trust already had a signed statement of Anne's authority which had been faxed through on 5th March, 2001.

Address given
9th June 2000

 Dear Mrs. Bean &  Mrs MacRae,
"I am writing to confirm that I have been in contact with your support group since March this year. I have given you my consent to act on my behalf in all matters relating to my health care.

Yours sincerely, 
A......"

Furthermore, Anne wrote another letter giving her permssion which was faxed through to the Executive of the Trust:

I give Mrs Bean, Director of SIN, and Mrs MacRae my full authority to act on my behalf in all matters relating to my health care. I also give them permission to update my case on the Internet......signed Mrs A....."

Discharge from Hospital, 13th April,Good Friday

After 5 weeks on the Ward, Anne decided to go home for Easter. During the last two weeks very little had happened. She left the hospital without a follow up appointment and much to her frustration and anxiety she had no written diagnosis, although the Consultant gastro-enterologist had prescribed  anti-tuberculin drugs.  These drugs had not been started on the Ward.

 The two TB drugs prescribed were: Rifater ( a potent triple combination TB drug containing  Rifampicin, Isoniazid, Pyrazinamide)  Ethambutol  together with Pyrodoxin for vitamin absorption. According to Mimms ( a monthly published Index of medical drugs), Rifater is usually  prescribed for acute pulmonary TB, which Anne did not appear to have. Also it states that special precautions for the drug are: liver impairment ( Anne had abnormal liver function tests and her CT scan had indicated some possible problem with the liver). and Porphyria ( it was suspected at one time that Anne had Porphyria) Also, the medical literature warned that Rifampicin should be monitored for renal toxicity and appropriate measures be taken to prevent a fatal outcome. Apparently this drug could cause "acute renal failure" ( ARF)

Anne's Reaction to the TB drugs

Anne was very worried about taking these powerful drugs unmonitored, and did not begin the regime  until Tuesday 17th April.  By Thursday Anne had had to stop taking the drugs because her abdominal pain was much worse. She likened it to a piece of jagged glass being dragged along her intestines. In addition she had developed severe bladder pain when trying to pass urine, in fact she had great difficulty in passing any  urine and on one occasion told us she had passed blood.  Anne rang her GP's surgery and reported how ill she was and her problem with passing urine.. No one came out to see her although she rang the surgery a second time. Anne said she had been bent double  crying out in agony.

On Monday 23rd. April, Anne got in touch with the Consultant's secretary. The Consultant gastro-enterologist  was away on holiday, and  no appointment had been made for Anne to see him again. The secretary  put her in touch with the TB nurse. Anne spoke to the TB nurse attached to the TB Clinic and she was told that it was routine for anyone being given TB drugs to be given an appointment with the TB consultant. The TB nurse was very concerned about Anne's state and and said she would try to get her in that afternoon, Monday being the TB Clinic, and if not then for the following Monday.  However, this nurse never got back to Anne and a secretary said that the nurse would get into trouble for having told Anne that she should have been referred to the TB specialist! What state is our hospitals in when a nurse is likely to get into trouble for speaking the truth, for fulfilling her responsibilities and  for trying to help a patient ? 

Anne then telephoned the ward and a nurse checked on the computer, but could find no appointment made for Anne. She put Anne in touch with a Registrar, whom she did not know. On hearing her symptoms he was most concerned and  told her the quickest way of getting back into the hospital was for Anne to  travel up to A&E. However, Anne felt too ill to go all the way up to London, possibly to wait several hours in A&E and with no surety of being admitted. Anne had had several bad experiences  of being rejected by various  A & E. departments. However, a letter from her  GP  would have ensured her admittance immediately!

Anne eventually heard that she had an appoinment with the Consultant Gastro-enterologist at his Out Patient's Clinic on Tuesday 1st. May.......

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Second Update : ANNE "PRESUMED" TO HAVE TB December 2001

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The consultation on 1st. May  with the gastro-enterologist was, from Anne's point of view, disastrous. It lasted over an hour.  Most consultations for iatrogenic patients do last a long time, presumably the consultant can then claim that  a great deal of time was given to this "difficult" patien).  Anne informed us that the consultant dismissed TB, dismissed the symptoms, including her swollen abdomen and suggested that her difficulty in passing urine was due to an infection. He declared he had no idea what was wrong with her and suggested that she saw a psychiatrist in line with all the previous consultants. When Anne protested , he declared that all these consultants could not be wrong.....( Perhaps not, but could this be a cover-up, because someone down the line had made a mistake? Could we  be witnessing a "closing of the ranks syndrome"? If so, it would be wicked and cruel. Mr. Alan Milburn acknowledged on 10th July in a statement on the D.o.H. website, that cover-ups can occur when mistakes have been made. If consultants all sing to the same" hymn sheet", then this forms a body of medical opinion which complies with the  Bolam principle for any potential court case. The nonsensical Bolam principle has at last been discredited see "'Bye, Bye Bolam" in "Our Comments").

Letter from consultant to GP!

This consultant sent a letter to Anne's GP ( a copy to Anne), dated 3rd. May, 2001. Apparently all tests had been normal  except for vitamin B12, although later on in his letter he wrote; "...the only remaining thing that I will consider would be a liver biopsy if her liver function tests become abnormal again."  ( Admitting  that her liver function tests had been abnormal).

He made no reference to the fact that Anne had had problems passing urine after she had taken the TB drugs  and did not record that she had suffered severe  abdominal pain merely remarking that: "... lasted only 4 days on treatment because of an increase in her abdominal symptoms.."  Furthermore, he made a  seriously inaccurate statement he said; "...She was started on medication at the time of discharge on 12th April..." Actually Anne was discharge from hospital on Friday 13th April, and did not start on her TB drugs for several days, beginning  on Tuesday 17th April, because she was frightened of taking them without a diagnosis. ( ( In Sin's opinion she should not have been given  them without a written diagnosis). 
 He did state: " ..A Mantoux test was strongly positive...". No mention of Anne's potentially serious problem  with passing urine!

He finished his letter by :"....My view is very much still that Anne is suffering from a somatization disorder and that I really think the only way forward for her is to consult with a psychiatrist with an expertise in this type of problem."  !!!!

How on earth can Anne somatise her:

* swollen abdomen
* her  hugely positive mantoux test
* her abnormal liver function tests
* Her CT scan which showed" attenuation of the liver, compatible with diffused fat replacement " ?

Letter from SIN to the Medical Director (copy to Chief Executive) dated 13th May,2001
 The heading for this letter was:

SIN  in addition to reiterating the question as to which other  tests for TB had been done  and their result, raised   a number of serious issues in this letter. Amongst them were:
1. That surely a strongly positive mantoux test + TB symptoms confirms that Anne has active TB within her system?
2. That TB drugs were started without supervision or monitoring. [ SIN has since learnt that it is highly irregular for any patient to be sent home with TB drugs. The standard protocol is for the patient to remain in hospital until stabilised on the drugs, which can cause very unpleasant side effects]. SIn asked why Anne was not retained in hospital and monitored.  Our letter drew the medical Director's attention to the fact that  she had suffered severe bladder  reactions and increased abdominal pain.
3. The question was asked as to why Anne was given Rifater ( which contains Rifampcin)  when in Mimms  ( drug book widely  used by doctors and pharmacists), states that Rifater is given for active pulmonary TB which Anne does not appear to have. However, the medical literature does state  re: "Acute Renal Failure":
" It is important that Rifmapcin ( Rifater) be monitored for renal toxicity and appropriate measures taken in time to prevent a fatal outcome" 
4. Request for a microbiologist to establish the exact strains if TB which Anne may have. ( NB In accordance with the notice board on the wall of the ward in which Anne stayed for 5 weeks]
so that she could  be prescribed the correct drugs.
5.Brought to his attention that Anne had sought the advice of the TB nurse who had promised to get back to her,  and that failing to do so  had  been a serious neglect of duty.
6. Why had Anne been given no follow up appointment with the TB consultant which was the accepted protocol at the hospital?
7. A reminder of the meeting of 24th November ( 6 months ago) when a doctor from the Health Authority confirmed that Anne's symptoms were those of TB of the abdomen.

SIn concluded its letter thus:
 "We demand that Anne is put under the immediate care of Dr******** the TB specialist as a matter of urgency for the exclusion of active pulmonary TB. Thereafter to be transferred, if necessary, to a specialist in extra-pulmonarry TB. That a micro-bacteriolologist identifies the strain(s) of TB from which she is suffering and appropriate drugs be given under  careful monitoring. There is no reason why Anne should not receive the standard care which Dr. ****** offers to other patients.

"You will appreciate the seriousness of  Anne's case and the relevance to Public Health issues ( see fax no. 5 dated 23rd. March) we therefore request a meeting with you and the Chief Executive." { request ignored again}

New blood tests taken by GP showed liver abnormalities

This meant that now Anne could be admitted for a liver biopsy. She went into hospital on 5th and 6th June and the biopsy was taken. According to the consultant the results were negative!
This was amazing, since a scan had shown "attenuation of the liver compatible with fat replacement" .

Difficulty in obtaining another appointment with the TB specialist
SIN contacted the Medical Director's Office and asked why Anne  had  not been referred to a TB  specialist which was understood to be the normal protocol. SIN was informed that Anne's GP must request a referral.  Anne's GP complied with this request - however, after a delay of several days it was discovered that no such request had arrived at the hospital. The Medical Director's Office suggested to SIN that another letter  from Anne's GP be faxed through immediately.

Anne eventually  saw the TB specialist again in mid-July.   She was told that this consultant was a chest specialist, and  therefore specialised in   pulmonary TB. The consultant conceded that Anne could have had the "active" form of TB in 1996 ( when she was acutely ill and coughing). The specialist prescribed a revised prescription of TB drugs and Anne was  told that she was "presumed" to have TB. The dictionary's definition of "presumed" is: "Supposed to be undoubtedly true" "taken for granted" !!!!

Anne was sent home again with a bag of TB drugs and told to contact a nurse at the local hospital if she should have any problems.

By a great deal of work and  pressure SIN has been successful in obtaining for Anne:
1.  a meeting with her GP & a Health Authority doctor
2. a verbal diagnosis of her condition from the Health Authority doctor on 24th November 2000:  "a low grade abdominal TB infection"
3. an acknowledgement from her GP that she was a suspected case of TB in 1996 -  pulmonary
4. an acknowledgement that she had not been registered for suspected TB in 1996
4. a Mantoux Test which turned out to be very positive
5. a meeting with the TB specialist 

SIN is still concerned about the following:
1. Although she was given a verbal diagnosis many months ago; has been referred to a TB specialist;  has been given potent TB drugs  on two occasions without monitoring and advice -  yet  she not received a  written diagnosis? Why?
2.  Has she now  been registered as a suspected case of TB?
3. Why, according to the hospital, have all the tests been "negative"( except for the liver scan)
 although she  has such obvious and worsening  symptoms? .
4. Why was she not retained in hospital for monitoring of the TB drugs when this is the accepted protocol?