Misdiagnoses a systems ‘meltdown’

IT WAS an entire systems failure that cost Ann Moriarty her life, patient advocate Rebecca O’Malley stressed yesterday.

Ms O’Malley, who went public after being wrongly given the all-clear for breast cancer, said it was unfair to blame Ms Moriarty’s untimely and tragic death from cancer on incorrectly read X-rays.

“I know that doctors and nurses make mistakes. They are human. But if you count how many mistakes were made in Ann’s case, surely she could not have been that unlucky,” said Ms O’Malley.

Ms Moriarty’s husband, Karl Henry, who lives in Ennis, Co Clare, and who has a 13-year-old son, said she was given the all-clear for breast cancer twice by Ennis General Hospital and also once at St James’s Hospital in Dublin in 2007.

Mr Henry said the misdiagnoses and other significant failings had been confirmed in two unpublished Health Service Executive (HSE) internal reports into his wife’s treatment.

He claimed the hospital had reported that two X-rays had been misread and that highly abnormal blood tests showing elevated tumour markers had be filed in Ms Moriarty’s notes without ever being acted upon by doctors.

“It was more than just one radiologist making a mistake,” said Ms O’Malley. “It was not just a single mistake — it was a complete meltdown of safety systems.

“There must be issues of clinical governance at Ennis General Hospital and these can only be identified by independent experts,” she said.

Ms O’Malley also said there was no communication with Mr Henry by the hospital as to how they were going to conduct their investigation or how they arrived at their conclusions.

One of the HSE reports recommended the need to address the volume of work and staffing arrangements in the hospital’s radiology department.

It also said the “prioritisation system” for reporting and the auditing of services to optimise patient safety needed to be tackled.

Another report highlighted that nurses had voiced their concerns with doctors in August 2007 when Ms Moriarty was discharged from the hospital’s accident and emergency department.

Ms Moriarty attended the Galway Clinic a few days later and was subsequently re-admitted to the Ennis hospital for further treatment.

The report recommended that junior medical staff must respect nursing staff and consider their contributions to the decision making process.

General secretary of the Irish Nurses Organisation, Liam Doran, said it had always held the view that the professional opinion of an experienced nurse should always form part of the overall decision.

Ms O’Malley said issues needed to be considered included how the hospital was managed and how departments communicated with each other to ensure mistakes did not slip through the net.

Both Mr Henry and his wife had made it very clear each time they visited the hospital that she had been treated for breast cancer. “People at the hospital should have been particularly alert to any signs of the cancer coming back.”

Ms O’Malley said St James’s Hospital also had serious questions to answer about Ms Moriarty’s treatment there.

Following a mammogram at the hospital in April 2007, Ms Moriarty had been given the all-clear for cancer but was diagnosed as being terminally ill four months later.

“Now the mammogram has gone missing, which is curious. But, even if it reappeared and was clear, one would still have to ask how much can we depend on these check-ups,” said Ms O’Malley.

If the tests were not available to clearly reassure patients, they should know that. “We cannot expect doctors to be gods but, if they do not have the tools to really identify a problem, patients should know that.”

Ms O’Malley said there appeared to be a culture in Ireland that made people very cautious about speaking out.

“There are people that acknowledge that these issues should be aired but wanted somebody else to do it for them,” said Ms O’Malley.

Mr Henry was concerned other patients might also have been incorrectly diagnosed at Ennis Hospital.

Both he and Ms O’Malley pursued the matter at the highest level within the HSE until a stage was reached where Mr Henry felt he had no choice but to go public in an attempt to resolve the issues relating to his wife’s treatment and its implications.

“He never wanted to go public on his wife’s death. He is doing this solely for Ann and because of the burden of responsibility he feels towards other people,” said Ms O’Malley.

Ms O’Malley knew that people must now be asking themselves if anything had changed since the recommendations were made by the Health Information and Quality Authority in relation to her case.

“I would like to think that, very slowly, things are changing but there is a long way to go and I think Ann’s case has highlighted huge governance issues in our hospitals there must be tackled.

“Good doctors and nurses need to know that they are not operating in a complete vacuum. They need to be given a framework within which to operate.”