Demand for review of HSE computer systems as error affects 25,000 scans and X-rays

A full review of the HSE’s computer system needs to take place after errors were detected in 25,000 medical scans.

That is according to Fianna Fáil, Sinn Féin, and the Social Democrats, who have demanded an immediate investigation into the error, which may have led to vulnerable people being given unnecessary treatments due to incorrect test results.

At least 25,000 X-rays, MRIs, CTs, and ultrasounds taken since 2011 are affected by the computer programming error, which was only identified last week.

The flaw arose with images of patients’ tests held at the HSE’s National Integrated Medical Imaging System (NIMIS). The exact issue relates to the use of the “less than (<)” symbol and it being omitted or not visible when being read in a report by a medical professional.

The consequence of this means patients could have been undertreated, overtreated, or not treated at all.

The HSE said last night that all hospitals and radiology departments operating NIMIS have been notified of this issue.

“As a precautionary measure, the HSE is reviewing the patient safety risks associated with this issue and as stated, an incident management team has been convened to manage this process,” said a spokesperson for the HSE.

The Irish Patients’ Association (IPA) called for a helpline to be set up by the HSE to offer information and reassurance to the thousands of people potentially affected by this error.

“Far more information is needed to alleviate fears and anxieties that patients may have,” said a spokesman for the IPA.

“From the public’s perspective, more information needs to be provided by the HSE.”

Dr Chris Luke, consultant in emergency medicine at Cork University Hospital, said it is unlikely that patients would be treated on the basis of one erroneous test report.

He said it would be potentially serious if patients were overtreated due to false positive results.

Dr Luke said it would be normal practice that such things would be picked up by multidisciplinary teams, where doctors confer on a range of tests and checks relating to patients.

He said doctors have an obligation to verify tests, repeat checks, and to look at all of the patient’s previous results.

Dr Ann Hogan, president of the Irish Medical Organisation, said she hoped very few people, “if no one at all”, would have to worry.

Prof Barry O’Sullivan, director of the Insight Centre for Data Analytics in UCC’s Department of Computer Science, questioned patient safety.

“If the HSE is using a system that is so wrong then how does it know that any of its systems are reliable?” he told the Irish Examiner.

“I’ve never heard of an error like this. The mistake is a really fundamental one.”

Demand for review of HSE computer systems as error affects 25,000 scans and X-rays

Speaking on RTÉ, Fianna Fáil health spokesman Billy Kelleher said an urgent, full-scale review is needed due to the seriousness of the issues involved.

“We need to have a full review on the HSE’s capacity in the technological areas to firstly draft contracts for purchase of software, but also to assess software and the implications of because we are moving into the digital era,” he said.

The Social Democrats’ Galway West general-election candidate Niall Ó Tuathail — who is a former health reform adviser to Britain’s National Health Service — also raised concerns.

“This flaw was an avoidable mistake. In the end, tech systems can’t replace clinical judgement and should only be used as a support,” he said.

Latest X-ray scandal part of long list

- Joyce Fegan  

The latest HSE X-ray scandal is just one in a long list of similar cases.

  • In August 2007, news of mammogram misdiagnoses broke at Midlands Regional Hospital in Portlaoise. The HSE informed the then health minister, Mary Harney, that breast radiology services had ceased after staff raised concerns about some results of ultrasound scans and mammograms. A review showed that more than 3,000 mammograms were carried out at the hospital between November 2003 and August 2007, but nine women given the all-clear were subsequently diagnosed with breast cancer. Three reports into the crisis were issued by the HSE, but neither staff nor equipment was included as part of these investigations, even though they were highlighted as concerns. An author of one of the reports, Dr Ann O’Doherty, estimated the mammogram machine at the hospital was 15 years old, which was five years past its decommissioning date.
  • In May 2008, it emerged that almost 4,600 people in the North-East of the country needed to have their X-rays and CT scans rechecked because of concerns about the work of a locum radiologist. The HSE sent letters to 4,590 patients of Our Lady of Lourdes Hospital in Drogheda and Our Lady’s Hospital in Navan stating that 6,000 X-rays and 70 CT scans, taken in 2006 and 2007, needed to be reviewed. A separate external review examined a number of cases in the region where people had been diagnosed with lung cancer but had their diagnoses delayed because of an abnormality on their chest X-ray not initially being spotted.
  • In March 2010, Tallaght Hospital was in the spotlight after it emerged nearly 58,000 X-rays, taken there between 2006 and 2009, had gone unreported.
  • In December 2010, a HSE audit triggered by the Tallaght scandal revealed a further 34,000 X-rays, taken in hospitals all around the country, had also been caught up in a backlog and had never been reported on. Backlogs were reported at Beaumont Hospital in Dublin, Connolly, Blanchardstown, Kerry General, Lourdes Orthopaedic Hospital, Kilcreene, St Luke’s Hospital Kilkenny, Midland Regional Hospital in Portlaoise, and Our Lady’s Hospital for Sick Children, Crumlin. There were also X-rays yet to be reported upon at Midland Regional Hospital, Tullamore, St Columcille’s Loughlinstown, Waterford Regional Hospital, Our Lady of Lourdes Hospital Drogheda, Cork University Hospital, Temple Street Children’s Hospital, the Rotunda, and Our Lady’s in Navan.
  • In March 2013, it emerged that more than 6,000 patients attending at Tallaght Hospital were awaiting results from X-rays, CT, MRI, and ultrasound scans. Doctors estimated the backlog meant their patients were waiting up to five weeks for results.


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