X-ray inquiry finds major failings

A REPORT has identified significant failings in how a huge backlog of X-rays developed at one of the country’s biggest hospitals and in how it dealt with thousands of GP referral letters.

The independent Hayes Report, published yesterday, criticised Tallaght Hospital in Dublin, for being “grossly understaffed” after a backlog of almost 58,000 X-rays were uncovered.

While the report found that there were no unopened GP referral letters, it identified “clear failings” in how the hospital dealt with the letters of the 3,498 patients affected.

The HSE has accepted the report’s findings and pointed out that it had been working with the hospital on its implementation plan, now “well under way”, to ensure all the recommendations were acted on.

Fine Gael’s health spokesperson, James Reilly, said it was deeply worrying that two additional consultant radiologist posts, the need for which had been clearly identified in the report, remained unfilled.

“This is risking a recurrence of this problem and putting patients at risk. There is really no excuse for such a lethargic approach to patient safety.”

The HSE said it had approved funding for two additional consultant radiologists posts in Tallaght and, together with the X-ray reporting guidelines now in place, was satisfied that the backlog of unreported films would not recur.

The report revealed severe systemic and other weaknesses at management level, while the structure of the hospital’s board was not strong enough to provide governance, supervision and direction.

The inquiry team, led by De Maurice Hayes, found that consultant radiologists expressed their concerns to hospital management on more than 30 occasions between 2005 and 2009.

A review of all 57,921 X-rays carried out by the hospital and completed at the end of April found no untoward event, no missed diagnosis and no undetected problem.

The report points out that the cases of two patients, identified earlier this year as having had delayed diagnoses and reported to the Health Information and Quality Authority, were not among the X-ray backlog.

Dr Hayes said a concerted effort has been made to address the unprocessed GP referral letters, with 97% of patients affected seen by a consultant at the hospital and the remaining 157 all offered an appointment scheduled to take place before the end of the month.

He said that the inquiry team had been advised that no serious event has been discovered and no patient appeared to have been endangered as a result of the backlog of GP letters.

The report blames the absence of a clear policy or written procedures and protocols for dealing with out-patient referrals from GPs.

The board of Tallaght Hospital said it accepted that serious issues were identified in the past and that this did not always lead to prompt and effective action.

A report on a national review of all hospital radiological facilities is being finalised and is expected to the completed in the next few weeks.