Kerry scans controversy: HSE under fire amid look-back at 46,000 files over missed diagnoses

Seven serious cases, all involving cancer, were missed or misdiagnosed by a staff member at University Hospital Kerry, a review of more than 46,000 files has found.

Kerry scans controversy: HSE under fire amid look-back at 46,000 files over missed diagnoses

A briefing for councillors, TDs and health forum members focused on the workload placed on the individual staff member. There was strong criticism also of HSE policy with regard to informing the public and the media.

In response to a query about the staff member from the Mayor of Tralee Norma Foley, Gerard O’Callaghan of the HSE said the consultant radiologist had previously worked in the UK and Canada.

One of the biggest ever look-backs in this country – involving 46,000 files including reports of scans, X-rays and ultrasound imaging involving more than 26,000 patients — is under way after three missed cancer diagnoses which came to light in July. The review has been under way since October.

The Irish Examiner understands the three cases which sparked the look-back and which had been missed were “very obvious cancers”.

They were followed by another four “serious” cases which had also been missed or misdiagnosed and those scans had taken place prior to July.

However questions were being raised by individual GPs and consultants prior to July, it also emerged.

Management revealed the additional serious misdiagnosed cancer cases following questioning by Cllr Toireasa Ferris (SF) who said she had been contacted by a fourth family since news broke of the review through the media on Sunday.

“This morning I spoke to the family of a constituent from Kerry who had a scan in early summer and as a result of an erroneous report on that scan received a delayed diagnosis for a serious cancer,” she said. Ms Ferris said had the family known they would have paid for a private scan but the cancer was now inoperable.

The review got under way in October. As of Monday 20,923 scans relating to 12,923 patients have now been reviewed by radiologists and there has been no major discrepancy found. The reviewers are working backwards chronologically from July and have so far covered the 2017 period. It will take a further 10 weeks to complete.

The review team of six external radiologists is being increased by two, Health Minister Harris had ordered.

The “look back” under way in Tralee was one of the biggest ever in this country, and Department of Health knew of it since July, according to Gerard O’Callaghan of the HSE.

Concerns had been raised earlier in the year about the work of the consultant radiologist but these were “less serious”, Dr Claire O’Brien, clinical director, confirmed.

A workload of 46,000 scans, X-rays and ultrasound images and reports by one individual over 16 months is astonishing, councillors and TDs said.

At first, the seven senior HSE personnel and hospital management team insisted the issue was wholly related to “competence” of one individual.

However, Cllr Aoife Thornton ( FG) said she could not accept that analysis. Other representatives also warned against scapegoating an individual.

Ms Thornton, a solicitor by profession said: “I am not convinced it is about competence. I am not satisfied it’s competency, that it is not workload.”

Fergal Grimes, UHK hospital manager, said the five-member radiology team was commensurate with the size of UHK. However, he also revealed some radiology department work was being outsourced “to release pressure” on the department.

General manager of University Hospital Kerry, Fearghal Grimes, at a press conference in the hospital. The hospital is conducting a review of over 46,000 scans or files that involve over 26,700 patients in an area that includes Kerry, North Cork and South Limerick. To date, 18,000 scans have been reviewed. Pictures: Domnick Walsh/ Eye Focus

General manager of University Hospital Kerry, Fearghal Grimes, at a press conference in the hospital. The hospital is conducting a review of over 46,000 scans or files that involve over 26,700 patients in an area that includes Kerry, North Cork and South Limerick. To date, 18,000 scans have been reviewed. Pictures: Domnick Walsh/ Eye Focus

If there are concerns regarding the workload on individuals that would be addressed, as part of the review, Mr Grimes also said.

Earlier, local GP Dr Gary Stack of Killarney said he would have raised concerns in relation to a small number of X-rays earlier in the year.

There was nothing major but the reports back raised the practice’s concerns. It was only when a number of other GPs and consultants also raised concerns that alarm bells would have gone off, he believed.

Concerns raised over workload of clinician in Kerry scans

- Evelyn Ring

Fianna Fáil health spokesman Billy Kelleher has said the workload of the clinician at the centre of the Kerry scans controversy would have been very heavy for any person.

It has emerged that 46,000 scans taken at University Hospital Kerry, including X-rays, CAT scans, and ultrasounds, need to be reviewed because of concerns about the clinical abilities of the person who examined them.

Mr Kelleher said many of the patients affected would have rightly thought that their health worries were behind them.

“To now find out that their scans need to be reviewed will cause severe anxiety and my heart goes out to them,” he said.

Mr Kelleher said Health Minister Simon Harris needs to explain what he knew and when he knew it.

“A hands-off approach, which is Minister Harris’ usual modus operandi, is not acceptable in this instance,” he said.

“The minister needs to set out what he is doing to prevent incidents like this from happening in the future at this or, indeed, any other hospital.”

Mr Kelleher said he was concerned that one person was responsible for reviewing so many different scans.

“It’s clear to me that, irrespective of their clinical abilities, this is a very heavy workload for any person.”

Celia Cronin, patient manager SSWHG. The hospital recalled 21 patients to have repeat investigations carried out, but no further action was required

Celia Cronin, patient manager SSWHG. The hospital recalled 21 patients to have repeat investigations carried out, but no further action was required

He said it seemed there was no oversight of the person’s work to ensure that mistakes were spotted.

It is not the first time that University Hospital Kerry has been at the centre of a radiological investigation.

In April 2015 the HSE said six patients were recalled following a review conducted between July and August 2013, but there were “no harm events”.

The locum consultant radiologist at the centre of the review was reported to the Medical Council in 2013.

Mr Kelleher said the clinical review team involved in the current review is due to complete its work in March.

“There can be no slippage in terms of meeting this target. Too many people are anxiously awaiting news of their own review, and the sooner it’s completed, the better for everyone concerned,” he said.

A spokesperson for the South/South West Hospitals Group said a “look back” process with independent oversight is under way on a portion of radiology investigations carried out between March 2016 and July 2017.

The review is expected to be completed within eight to 10 weeks. Since October 18,000 images have been reviewed and 21 patients recalled, but none have required further action.

Labour health spokesman Alan Kelly asked why the public is only finding out now about the review.

His Kerry colleagues, Cllr Graham Spring and Cllr Terry O’Brien, told him there is “enormous concern” in the locality because of the misdiagnosed scans.

Mr Kelly said there must be an independent review of what happened.

Cllr Toiréasa Ferris (SF) called for a full explanation of how 26,700 patients are now having their scans reviewed because of concerns around potential misdiagnoses.

“My information is that concerns may have been expressed some time ago that there may have been an issue with scans,” she said.

“Incidents such as this damage confidence in our public health services, but delays in addressing them are of equal concern.”

Q&A: The who, what, when, where, and patients affected

- Evelyn Ring

When did the hospital realise there was a problem?

Towards the end of July, this year management was alerted about a missed cancer diagnosis for one patient.

In August two other cases of a serious nature were identified that resulted in patients getting a delayed cancer diagnosis.

Who is affected?

Over 26,000 patients are involved in the review of 46,000 X-rays, ultrasound and CT scans.

Where are they from?

The patients at the centre of the investigation are from the hospital’s catchment that includes Kerry, North Cork and South Limerick.

When did the review start?

It started in October, and the scans were all taken between March 2016 and July 2017.

What has the review discovered?

The HSE has said no critical failures have been identified since three delayed cancer diagnoses emerged during the summer.

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Have patients been called back as a result of the review?

The hospital recalled 21 patients to have repeat investigations carried out, but no further action was required.

How many scans have been reviewed?

A hospital radiologist, together with six external radiologists, have reviewed 18,000 scans.

The hospital hopes to complete the review in eight to ten weeks.

What are radiologists looking for?

The radiologists are looking for possible abnormalities but are most concerned that there may be a delay in a cancer diagnosis.

What is also on their checklist?

They are looking out for missed infections, missed bone fractures, heart failure and diseases that affect the organs.

What happens if there is concern that a patient requires a repeat investigation?

A clinical member of the hospital will contact the patient and his or her family to arrange a further investigation and any follow-up care that may be required.

How did the need for such a major review arise?

The work of one individual — a previous employee of the hospital — is being examined.

The person has resigned from the hospital.

Does the hospital know if the former staff member at the centre of the review worked anywhere else or is working somewhere now?

The hospital said it was not in a position to answer this question.

How do the radiographers working at the hospital feel?

According to Siptu, the hospital’s X-ray department is “a very unhappy” place to work in.

What do the radiographers want?

They want more personnel and equipment. A report published in December 2016 identified a deficit in staff levels.

Does the hospital agree with the union’s argument on staff and equipment?

Clinical director of University Hospital Kerry, Dr Claire O’Brien, said they believed that the department was safe and the service was appropriate.

What is her chief concern?

It is about the work of an individual who worked in the hospital and who is not a radiographer.

But more radiologists are needed according to Siptu. Does she agree?

Dr O’Brien said the resourcing of the radiology department in such a busy hospital was always challenging, but management was dealing with the situation.

What about the particular case being looked at?

The director said it was not a “resource issue” that impacted on the work of the individual that is now being examined by radiologists.

Why did the hospital not announce that a major review was under way?

The hospital believed that while it was a large-scale review, the number of people affected would be very small.

What about transparency?

The hospital said it did not want to cause unnecessary worry and distress for patients.

Was the hospital correct in believing that the numbers would be quite small at this stage of the investigation?

Yes, because it has now reported on a substantial number of the radiology images.

How does the process work?

A clinical co-ordinator has been identified to co-ordinate as necessary with patients, arranging appropriate clinical follow-up.

Any patients needing urgent intervention will be immediately contacted before the full audit is complete.

Timeline

- Evelyn Ring

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