MANY IMPROVEMENTS have been made at Our Lady’s Hospital for Sick Children in Crumlin, Dublin, since a wrong kidney was removed from a child two years ago.
Yet not all the findings of an independent inquiry into the incident have been implemented, the chairman of a Medical Council fitness to practise inquiry said yesterday.
Dr John Monaghan said all the findings of the inquiry should be implemented “forthwith”.
He was speaking after the fitness to practise committee cleared two doctors from Crumlin hospital – Prof Martin Corbally and Mr Sri Paran – of allegations of professional misconduct arising out of the wrongful removal of a healthy kidney from a now eight-year-old boy in March 2008.
The boy’s mother Jennifer Stewart told the first day of the fitness to practise inquiry in May she was under the impression her son was to have his right kidney removed since an outpatient appointment at the hospital on January 17th, 2008.
However, Prof Corbally took an erroneous note of that consultation, recording that the boy needed his left kidney removed. It set in train a series of events which culminated in the child having his healthy kidney removed two months later, leaving him with a 9 per cent functioning right kidney.
Prof Corbally had delegated the surgery to Dr Paran, a junior doctor at the time.
In evidence yesterday, Dr Paran said it would have been “frowned upon” had he not followed the direction of his consultant (Prof Corbally) when the consultant pointed to where he should make an incision on the child’s abdomen before proceeding to operate to remove the kidney. The consultant pointed to the child’s left side.
Dr Paran admitted he should have looked at the child’s X-rays before proceeding with the operation but said he was given less than five minutes to prepare for it, the child was also already anaesthetised when he realised he was doing the operation,and when Prof Corbally pointed to where he should break the skin and asked him was he happy to get on with the operation, he proceeded.
“When a consultant says to you where to make an incision, you trust that he has done whatever needs to be done . . . as a mentor not only is your job to train the person but also you have a job to protect the person so I trusted what I was told,” he added, before becoming emotional.
Asked by his counsel Charles Meenan how he felt after the operation he said: “Bad. Not as bad as the parents, but bad.”
Questioned as to why he did not look at the X-rays at any stage in theatre, even when it appeared at first that the kidney he was operating on wasn’t too bad he said: “I’ve been asking myself that question for two years. I don’t know”.
Dr Paran, a native of Sri Lanka who, like Prof Corbally, studied medicine at UCG, is now waiting to take up a consultant post in paediatric surgery at Crumlin and Tallaght hospitals.
Prof Corbally told the inquiry earlier this week that Dr Paran had at least 30 minutes to prepare for the operation and it only took minutes to review the X-rays, which he expected him to do.
He added that he himself was not dictatorial and regarded himself as Dr Paran’s friend and mentor.
Before clearing the two doctors of professional misconduct yesterday, Dr Monaghan said the fitness to practise committee took most seriously the view of the parents that this type of catastrophe should not be allowed to happen again.
He also said the dignity of the boy’s parents in giving evidence in stressful circumstances had been noted. In addition, and quoting an expert who never got to give evidence, he said “the hierarchical gradient in the surgical team” and excessive differential behaviour factored against critical analysis of decisions in this case. “We wish the two doctors would address this in preparing their guide for the Medical Council,” he said.
They have undertaken to prepare a guide on how such a tragedy can be prevented again.
Furthermore, Dr Monaghan recommended the transcript of the inquiry be published for the further education of doctors.
He added that the boy in this case had medical problems even before “this disaster” but he may unconsciously have contributed to improvements in medical care and the committee hoped he would lead a fulfilling life.
The boy’s mother told an earlier hearing he had “done much better than expected” after the blunder and was now attending school, but she and his father “worry each day” about when he’s going to need dialysis and a transplant. “We are just living day by day,” she said.
She also confirmed the family, who have two younger children, were pursuing a legal action against the hospital.
Dr Monaghan noted that only senior doctors could now seek consent for operations in Crumlin, that there had been a change in the management of X-rays and “time out” is now taken before surgery commences.
Meanwhile, in response to a claim by Prof Corbally that there were 18,000 unfiled X-ray reports and letters at Crumlin in February, the hospital said last evening it wished to reassure patients “there is no problem at the hospital in relation to unfiled reports”.