A number of doctors involved in the care of an elderly man before he bled to death at Monaghan General Hospital have been criticised in an independent inquiry, the findings of which were published by the Health Service Executive yesterday.
The damning report into the death of Pat Joe Walsh has, as a result, been referred to the Medical Council.
Management of health services in the northeast also come in for criticism in the report. No action has been taken against any member of the management team.
The report refers to the "sustained failure" of management to resolve issues such as interpersonal difficulties between hospital consultants in the region.
One of the most controversial of the report's recommendations is that in-patient medical services in Monaghan hospital "cease at the earliest possible opportunity". The HSE said this recommendation will be acted on on a phased basis but it does not have a time-frame for the change.
Mr Walsh (75), from Killanny, Carrickmacross, died of a bleeding ulcer at Monaghan hospital on October 14th, 2005, after staff in the hospital failed in their bids to transfer him to three other hospitals for emergency surgery. Monaghan hospital sought the transfer because it is not permitted to carry out such surgery.
The inquiry team found that while Mr Walsh's death may have been inevitable, it was "avoidable in the circumstances in which it occurred".
It noted that Mr Walsh had been recovering from a hip operation and a bleeding ulcer at Our Lady of Lourdes Hospital, Drogheda, when he was transferred to Monaghan for rehabilitation on October 13th, 2005.
While his condition was stable after transfer, within hours his ulcer began to bleed profusely and efforts were made by a junior doctor in Monaghan to transfer him back to Drogheda, as well as to Cavan General Hospital and Beaumont Hospital, but to no avail.
The inquiry team said it believed the consultant on call in Monaghan, Dr Roy Cazabon, should have phoned the on-call consultants in the other hospitals in an attempt to effect the transfer himself.
"The reviewers believe that the failure of the on-call consultant in Monaghan hospital to make direct telephone communication to the on-call consultant in the other hospitals or to consider the option of directly transferring Mr Walsh by ambulance fell short of good clinical practice."
The reviewers also believed that "the unwillingness of surgeons in OLOH [ Our Lady of Lourdes Hospital] and Cavan hospitals to immediately accept Mr Walsh was unacceptable".
The consultant surgeon on call in Drogheda was named as Mr El-Masry who, the report said, recommended that Mr Walsh be sent to Cavan, which was nearer to Monaghan.
A junior doctor in Cavan said he was told by the on-call consultant in his hospital on the night, Mr Noel McMurray, not to take the patient as there were no intensive care (ICU) beds available.
However, Mr McMurray told the inquiry he had declined to take the patient not because of the lack of an ICU bed, but because he was working under guidelines that precluded him from undertaking such major emergency gastrointestinal surgery.
The review team said that while they accepted Mr McMurray's statement as to the policy in operation at that time, "they are not clear that his refusal to accept the patient was solely on this basis".
The report also said that "Drogheda hospital staff . . . had a clinical responsibility to take Mr Walsh back without hesitation, particularly in the light of the known restrictions placed on the surgical staff in Cavan/Monaghan."
One ICU bed was available in Drogheda and two were available in Cavan to which Mr Walsh could have been transferred, the report said.
Overall, the review said the "events occurred not primarily as a result of individual clinician failures, but as a consequence of dysfunctional processes, relationships and management structures".