Report uncovers systematic problems

THE man who headed the State’s probe into the misdiagnosis of a breast cancer patient was “surprised and disappointed” but not “horrified” when it revealed systemic mismanagement at two HSE hospitals.

A review of the botched cancer test of Tipperary woman Rebecca O’Malley by the Health Information and Quality Authority found it was caused by a once-off interpretative mistake by a locum consultant pathologist at Cork University Hospital.

The report, however, was highly critical of the way Ms O’Malley’s case was dealt with by the Health Service Executive, the Mid-Western Regional Hospital in Limerick and CUH.

It also found that a second patient, known as Ms X, who underwent a sub-optimal diagnosis at the Mid-Western hospital in March 2005, was later found to have breast cancer.

Ms X was one of seven patients identified by the authority in September 2007 as requiring a precautionary follow up after their review of a further 24 cases.

It was discovered, however, that Ms X, who was given the all-clear in March 2005, went to her doctor in July 2007 complaining of discomfort in her right breast and was later diagnosed with breast cancer.

She underwent a mastectomy last December and in January wrote a letter of complaint to the Mid-Western hospital.

The head of the authority’s investigation team, Dr Michael Durkin, said there were significant shortcomings in communication within and between the hospitals and the HSE, leading to a disjointed and delayed response to Ms O’Malley.

There was also a lack of accountability, cohesion and focus on the needs of Ms O’Malley in responding to her concerns.

“These were a symptom of systemic problems of under-developed and ineffective management systems within the hospitals,” he pointed out.

Asked at a press conference in Dublin if he was horrified at what the investigation uncovered, Dr Durkin replied: “I would not say horrified, but I would say surprised and disappointed.”

The authority found there was a disconnection between management and clinical staff at a local level, as well as between the hospitals and the HSE’s National Hospitals Office.

Consistent themes from their interviews included significantly increasing workloads not matched by resources and recurring difficulties and delay in securing additional staff, as well as disillusionment with the role of the HSE.

The authority’s chief executive, Dr Tracey Cooper, stressed that there were excellent centres in Ireland dealing with symptomatic breast disease. But, she said, those centres that were not delivering a high quality of care needed to take on board the 15 recommendations made in the report.

“There are important lessons for those responsible for providing services and, when the recommendations contained within the report are implemented, the authority believes the experience of Rebecca O’Malley should not be repeated,” she said.

She pointed out that the authority and the HSE would be agreeing on a timeframe for the authority to periodically check that the recommendations were being implemented.

Ms O’Malley, 42, who welcomed the report, said there should be no more “Russian roulette” with patient safety.

“I suspected that the report would reach disturbing conclusions, but I did not anticipate that it would paint such an incredibly bleak picture of a service that is increasingly characterised by failure and dysfunction, rather than by success and safety,” she said.

Ms O’Malley, who underwent a mastectomy in a London clinic after being diagnosed with breast cancer in 2006, discovered in April last year that her crucial treatment had been delayed by 14 months due to a misdiagnosis in 2005. She went public with her story in May when she failed to get an answer from the health authorities as to how her misdiagnosis occurred and who else may be affected.

The HSE welcomed the report and again apologised to Ms O’Malley and her family for the distress caused. The health authority said it accepted the report’s 15 recommendations and pointed out that a number had already been implemented and others werein the process of beingintroduced.

The implementation of the recommendations will be overseen by the HSE’s national director of the National Hospital’s Office, who is working closely with the director of the Cancer Control Programme.