Pathologist made errors in 50 cancer biopsies
The review, conducted by the Health Information and Quality Authority was set up to investigate why the hospital wrongly diagnosed a woman as not having cancer on two occasions over an 18-month period.
When the authority’s investigation team examined the work of the pathologist, referred to as Dr C, a further 49 discrepancies were identified.
The report said his error rate was 5-6 times greater than the accepted range.
The authority’s review also revealed that when the hospital recruited Dr C they failed to check his credentials, which would have revealed he had two “notifications” on his record in Finland for failing to diagnose cancer.
Although not named in the report, Dr C has been publicly identified as Finnish consultant Dr Antoine Geagea. He was employed as a temporary consultant pathologist in the Galway hospital between September 2006 and March 2007.
Of the 49 additional cases revealed by HIQA:
* There were delays in the diagnosis of cancer in three cases (of nine months, 16 months and 17 months respectively).
* Delays in diagnosis of benign disease in nine other cases.
* No change in care of the remaining 37 cases because their condition was either known or diagnosed in other tests.
Dr Michael Jeffers of the investigation team said some of the 49 patients were now dead but said Dr C’s tests had no impact in terms of their care. He said of the three cancer cases where the diagnosis was delayed the individuals were “alive and well”.
He said the delay “would not be expected to make a material difference to their outcome”.
But Rebecca O’Malley of Patient Focus, who was wrongly diagnosed in a separate case, said she had been contacted by one of the people affected, who said she wasn’t reassured.
“I know one particular case — somebody has contacted me — and it has made a difference to them.
“Their concern is that it’s the treating doctor whose saying it wouldn’t make a difference. They are not reassured by that, so they are seeking independent medical opinion whether the diagnosis delay has made a difference to their treatment.”
The HIQA review found that two consultants, Dr B and Dr C, failed to diagnose a woman, known as Patient A, in two tests; the first, by Dr B, in 2005, and the second, by Dr C, in 2007. The report described these mistakes as “two significant errors”.
In a hard-hitting audit of cancer care at the hospital, the report said:
* No “triple assessment” (by surgery, radiology and pathology) was carried out on Ms A’s results, or any individual results, to spot wrong diagnosis.
* There was no multi-disciplinary team meetings to discuss such results.
* There was no formal arrangement between UHG and Barrington’s Hospital in Limerick, where Ms A’s samples were taken, to discuss her results.
The authority’s chief executive Dr Tracey Cooper described Dr C’s recruitment process as “flawed”.
After leaving the Galway hospital, Dr Geagea worked at Cork University Hospital between July and August 2007.
A separate, internal, HSE review of his work there is due to be published soon.
* The National Standards for Symptomatic Breast Disease Service (2007) should be applied to all centres providing such services, including public, private and voluntary sectors.
* Regular multidisciplinary teams must meet to identify errors.
* The HSE and voluntary sectors should undertake a review of their services and the private sector also encouraged to do so.
* The HSE should ensure hospitals are less reliant on temporary staff.
* A formal policy on recruitment of locum and temporary consultant staff should be established to ensure more robust and effective checking of references and competency.
* The HSE should appoint a director to implement the recommendations.
CONNECT WITH US TODAY
Be the first to know the latest news and updates
