Patients who present at Cavan General Hospital in need of complex surgery are now to be considered for referral to Our Lady of Lourdes Hospital in Drogheda.
The decision, which will be made on a case-by-case basis, follows a preliminary review of 15 adverse clinical incidents which occurred at Cavan hospital's surgical unit between September and December last.
The review, carried out by the North Eastern Health Board's medical adviser, Dr Finbar Lennon, was ordered following the death of nine-year-old Cavan girl Frances Sheridan last month, three weeks after she underwent an appendix operation at the hospital. Hers was not among the 15 cases Dr Lennon examined.
In the cases he looked at, nine of the patients are now dead. Thirteen underwent surgery in Cavan and seven died within 30 days. Of the six who survived, four developed serious post-operative complications. The other two cases involved patients who presented in a critical state with acute surgical emergencies and died within five and 18 hours of admission.
A summary of Dr Lennon's report was published yesterday by the North Eastern Health Board, which runs the hospital. Most of the patients were elderly, their average age being 75. Dr Lennon found all 15 were "high-risk cases where a significant post-operative morbidity and mortality rate could be anticipated".
However, his report said that because each of the cases posed difficult and complex clinical management problems, transfer of these patients at an early stage to another hospital with a special GIT (gastro-intestinal tract) surgical service should have been considered.
Furthermore, it found some patients had their treatment delayed. This was because of "an undue dependence" on Dublin hospitals for clinical and radiological expertise, which was often not readily available. Also the involvement of medical and anaesthetic teams, which while appropriate, tended "to blur" the lead role of the surgeon in the management of the patients' primary illness, which was surgical. "The consequence of this on occasions was to delay necessary surgical decisions on patient management."
Dr Lennon felt the run of adverse outcomes demanded careful analysis and scrutiny. "When a surgical unit experiences an increase in morbidity and death rates it is very important that an internal review or clinical audit is carried out. If regular audit meetings take place in a clinical unit, such adverse trends are identified at an early stage and corrective measures can often be put in place . . . It is unfortunate that regular clinical audit meetings did not occur in the surgical unit in Cavan. The deficit was present well before the events which are the subject of this review," the report said.
The audits stopped during a period of interpersonal difficulties between two surgeons at the unit who were suspended last August. However, with their suspension went their expertise.
Critically Dr Lennon found it was "likely that one of the principal causes of the high number of adverse outcomes was the inadequacies in the assessment and selection process for surgical interventions. There was an absence of clear surgical leadership which was understandable in the circumstances. In addition there was a lack of direction from the respective clinical teams in the care of patients on occasions when key members of the team were absent or had changed with the unplanned arrival of short-term consultant locums."
The health board said last night if the next of kin of any of the cases reviewed still had concerns, they would be offered an independent review of the care and treatment given to their relative. It also revealed that 3,250 adverse incidents were reported by hospitals in its region last year. This is out of a national total of 26,000 such incidents.