A MEDICAL inquiry into two surgeons responsible for the removal of the wrong kidney from a young boy at Our Lady’s Hospital for Sick Children in Crumlin was dramatically halted yesterday after the committee invoked a new piece of legislation to terminate proceedings.
The Fitness to Practise Committee of the Irish Medical Council (IMC) decided to stop the inquiry without hearing all the scheduled evidence on the basis that the two doctors have given a number of undertakings about their future conduct.
Such a course of action is allowed under a little-known section of the Medical Practitioners Act 2007.
The decision means that no findings of professional misconduct have been made against either consultant paediatric surgeon, Professor Martin Corbally, or specialist surgical registrar, Sri Paran.
However, the decision was opposed by Patrick Leonard, representing the IMC’s chief executive, who argued that they had proven the charges against the two doctors.
Both surgeons had faced a series of allegations that their actions which led to the removal of the boy’s wrong kidney in an operation at Our Lady’s on March 21, 2008, had fallen seriously below the standards expected of medical professionals with their expertise and experience.
However, the committee chairman, Dr John Monaghan, said it was decided that the allegations had not been proven beyond reasonable doubt. Although there had been “a series of catastrophic errors,” Dr Monaghan said they were not satisfied that such mistakes represented malicious intent. He claimed the ruling was “an appropriate way of dealing with a tragic outcome”.
As a result, Prof Corbally and Mr Paran have promised not to carry out any surgery in future without first reviewing all X-rays of patients as well as not delegating any operations to a junior colleague without ensuring they are adequately trained and prepared to carry out the procedure.
They have also agreed to jointly submit a guide to the IMC within the next 12 months on lessons learnt from the controversy and how to prevent the same mistake being repeated by other doctors.
The committee praised the dignity of the boy’s parents who gave evidence in the case in stressful circumstances. Dr Monaghan also praised the now eight-year-old patient whom he claimed had unconsciously contributed to improvements in medical care.
Dr Monaghan highlighted the view of an independent expert who noted that the hierarchical system within the hospital’s surgical team allowed “excessive deferential behaviour” which worked against a critical analysis of decisions.
The committee noted that there had already been significant improvements in practices at Our Lady’s since the incident and called for any outstanding recommendations from an independent review not yet in place to be implemented immediately.
The boy’s parents, Jennifer Stewart and Oliver Conroy, declined to comment after the hearing. However, in a statement, they said that lessons must be learnt from the experience.
“This mistake of not reviewing must never reoccur. Medical professionals have the lives of our children in their hands and they must realise that when they are making decisions. Hierarchical systems must not exist in the interests of safety and quality of life. Everyone must learn from each other and uphold best practice,” read the statement.
It continued: “The doctors must be open, trusted and clear in their approach to work and their colleagues which was not present in the treatment of our son and it has ultimately led to where we are.”
“Professor Corbally and Sri Paran have to employ best surgical practice going forward. They owe this to our son,” the statement concluded.
The only consolation is case forced a changes in practices
This kind of human error must never be allowed happen again, writes Seán McCárthaigh
WHEN one of the country’s top paediatric consultants recorded the wrong kidney to be removed in a young patient during an outpatients clinic in January 2008, little did anyone realise the tragic consequences which would flow from such a simple mistake.
Such a “human error” as Professor Martin Corbally termed his incorrect handwritten note was to set in train a chain of events which led to a perfectly healthy kidney being removed from a six-year-old boy at Our Lady’s Hospital for Sick Children in Crumlin two months later.
The most shocking fact of the entire case, which unfolded during a hearing of the Irish Medical Council’s Fitness to Practice Committee in Dublin this week, is that neither Prof Corbally nor any other doctor ever consulted the patient’s X-rays in the period between the clinic and the actual surgery.
It is all the more alarming against the background that the boy’s parents had repeatedly questioned in the run-up to the operation if the correct kidney was being selected for removal.
On four occasions in the 24 hours before the surgery, including at the door of the operating theatre just minutes before the procedure, they sought reassurance from medical staff at Our Lady’s.
Had any doctor at any stage consulted the boy’s X-rays, it would have been immediately obvious to a trained medic that the wrong kidney was scheduled to be removed.
The inquiry heard evidence that there were three occasions when a possible doubt had either been mentioned to Sri Paran – the junior surgeon who actually carried out the operation at short notice – or occurred to himself before the kidney was irreparably removed.
Yet Mr Paran never looked at the X-rays even though they were lying close at hand on the patient’s trolley. It is a failure which the Sri Lankan medic, who has since been promoted to a full consultant, could not explain.
While both doctors have readily admitted they made basic mistakes which could have prevented the tragedy, the inquiry heard unsurprising evidence of the onerous workload under which surgeons at Our Lady’s operate on a daily basis. Average working weeks of 80 hours are the norm for consultants and their registrars, the committee heard.
In such circumstances, it is hard not to feel sympathy for the two highly-respected surgeons, who spoke movingly about the impact of their mistakes, out of the realisation that such a pressurised and under-resourced workplace will inevitably lead to a systems failure.
Prof Corbally revealed during the inquiry that there is a significant issue regarding the availability of X-rays for medical charts at Our Lady’s while also pointing out that more than 18,000 X-rays and letters remained unfiled at the hospital last February.
When the hearing opened last May, the boy’s mother, Jennifer Stewart broke down as she recalled how she and her husband, Oliver Conroy, had repeatedly expressed concern to doctors and nurses at Our Lady’s about the choice of kidney. In one heart-rendering piece of evidence, she remarked: “We had done all we could do.”
Ms Stewart admitted she abandoned her own gut instinct because she was pregnant at the time and felt “scatterbrained”. However, she also hinted that she had adopted the common position – that of “doctor knows best” – as she acknowledged that she was too embarrassed to challenge the surgeons about her son’s kidney.
Fortunately, the remaining damaged kidney, which only had 9% of its normal function at the time of the operation, has continued to perform better than expected over the past two-and-a-half years. However, the boy, now aged 8, and his parents still live with the constant fear that he will require either dialysis or a kidney transplant at some stage in the future.
Yesterday’s decision by the committee to halt proceedings, which means no findings at all, including potential ones of professional misconduct against the two doctors have been made, is somewhat unsatisfactory and could be regarded as a “fudge”.
The only consolation from the case is that it has led to a series of changes in practices, procedures and protocols at Our Lady’s designed to prevent a similar incident happening again.
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