Bereaved family battled HSE over unopened results

THE family of a woman who died while her test results lay unopened in a consultant’s pigeon hole battled for a year to get the hospital to explain the oversight, it has emerged.

A partial explanation was only forthcoming after the Ombudsman intervened in the case.

In the meantime, the dead woman was sent a further hospital appointment and an application form for renewal of her medical card.

Ombudsman Emily O’Reilly yesterday published the report of her office’s five-year investigation into the affair which found contradicting accounts of how consultants’ post was handled and whether public and private patients were treated differently.

She also found information was withheld from the woman’s GP when he asked about her results.

The Health Service Executive last week agreed to pay €5,000 “time and trouble” payment to the woman’s family, after protesting for three months that it may be in breach of their budgetary responsibilities to do so.

The investigation was into the death of a 53-year-old mother of two who was referred by her GP to a consultant in Mayo General Hospital after reporting shortness of breath and rapid weight loss, and was referred from there to Merlin Park Hospital in Galway for a lung function test.

Four days later, she collapsed at home and died in an ambulance on the way to Mayo General. Her test results, which showed a significant abnormality, had been posted to Mayo General and were found unopened in the consultant’s pigeon hole 10 days later, following queries by her GP.

Her family spent most of the next year trying to find out what happened without success, before contacting the Ombudsman. The hospital then apologised but provided only partial information.

The Ombudsman had to seek independent medical opinion as to whether the woman could have been saved if her test results had been read. The opinion was that her imminent death could not have been predicted and that she would have been referred for more detailed tests.

“This was a relief for the family. Her husband was quite convinced that his wife had died because she had not received medical attention after those results,” Ms O’Reilly said.

“A lot of additional trauma could have been spared to the family if this had been dealt with in a very open and honest and transparent way from the start.”

Ms O’Reilly said she was very concerned at the conflict of evidence she received in interviews. Hospital management and staff said post relating to the consultant’s public patients was sent to the general secretarial pool and that it often backed up in his pigeon hole there so they had to phone him and remind him to come and attend to it.

The consultant and his secretary, however, insisted their system was to have all post, public and private, sent to her for daily opening.

The consultant had no explanation as to why he removed a note from Merlin Park explaining the test results when he eventually gave them to the GP.

Ms O’Reilly said Mayo General accepted the points raised in her report and committed to addressing them while the HSE also accepted the report in full.