Inadequate training of doctors at fault

INADEQUATE training among all grades of doctors was the underlying reason for the miscarriage misdiagnosis scandal, an in-depth investigation has shown.

National and international experts commissioned by the HSE to uncover the reasons behind the crisis have found that training standards — not equipment flaws — led to women being told they had lost their pregnancy.

According to the report, half of all hospitals where misdiagnoses which came under the review occurred, had no mandatory training for ultrasound use at the time of the incident.

A further eight of the 24 cases took place at facilities which did not clarify the situation.

In addition, just three of the doctors involved had formal training in early pregnancy ultrasound use, while consultants and registrars accounted for 79% of all initial miscarriage errors examined.

“There are always a multitude of reasons (for an incorrect scan), but the biggest problem is a lack of training,” Prof Ledger confirmed.

As a result, the review group has recommended a series of mandatory training programmes for anyone working with women in their early stage of pregnancy.

When the misdiagnosis scandal first emerged, it had been suggested that out-of-date equipment may have caused the inaccurate readings.

However, Prof Ledger said the vast majority of the equipment in use at Irish hospitals is working effectively. Just six hospitals are using ultrasound technology more than five years old, while the HSE and Health Minister Dr James Reilly have given a commitment to make funding available to replace any equipment which could be a risk to patients.

The review group has also found that in many of the cases it examined, ultrasound scans took place at inappropriately early stages, increasing the risk of a misdiagnosis.

In 12 of the cases, the first ultrasound was taken in the seventh week of pregnancy or earlier, while in 15 of the 24 incidents no change was recorded in the second scan — almost all of which also took place within the first two months.

While the initial misdiagnoses were corrected by the second or third ultrasound in 21 of the cases reviewed, in one unspecified case a woman was only told she was still pregnant after the sixth scan.

Drug or surgical procedures to remove a foetus which had wrongly been thought lost were recommended on the first or second scan in 88% of the cases, risking the pregnancies of 21 women.

During the five-year timespan of the review, just over 375,000 births and 70,000 miscarriages were recorded in Ireland.