A Health Service Executive report into the death of a 31-year-old woman after treatment at Our Lady of Lourdes Hospital in Drogheda has found the hospital “completely failed her”. The review also said it was “very concerned” that, after reports into other adverse events at the hospital, the delayed diagnosis of Sharon McEneaney had occurred.
"This calls into question the standards of care and the safety culture and priorities in the hospital," it said.
The report also raised "major concerns" about the "administrative and organisational skills" of the consultant obstetric gynaecologist in charge of Ms McEneaney's care.
Though unnamed in this report, Dr Etop Samson Akpan was found guilty of poor professional performance in respect of the case by a Medical Council fitness-to-practise committee in January. The sanction imposed on him has not yet been made public.
Ms McEneaney, a creche manager from Carrickmacross, Co Monaghan, had a cancerous tumour in her abdomen and died in April 2009.
She first went to the Co Louth hospital's emergency department in October 2007, with abdominal pain. She had previously been diagnosed with neurofibromatosis, a condition which increased her risk of developing a malignancy.
On November 7th, after a third visit, she was admitted to the hospital where a scan showed up a mass.
Dr Akpan suggested she be discharged and readmitted for explorative surgery within two weeks.
Ms McEneaney wasn't readmitted until December 19th. When Dr Akpan operated on her, he found the large mass. A surgical team specialist said a biopsy should not be carried out due to the risk of bleeding. He recommended a CT scan and a "radiologically guided" biopsy. A CT scan was not done until January 24th, 2008, and Ms McEneaney returned to Dr Akpan on February 13th.
He said he left a note on her chart to refer her for the biopsy, but it did not take place. Instead, on April 3rd, she was given another ultrasound. She was only given a biopsy after the intervention of former TD Dr Rory O'Hanlon in late June 2008. She was treated for cancer in July, but died the following year.
The examination of the case was carried out by a panel of external reviewers chaired by Pat Gaughan, retired chief executive of the Midland Health Board. Though completed in 2010, it was not published.
The review found Dr Akpan was "caring, hard-working, compassionate and reflective". But "major concerns arose regarding his administration and organisational skills possibly compounded by workload, cross-site clinical commitments and in-hospital clerical support". It said that while the consultant's management plan for the patient was clear, "follow-through was lacking".
"While it is not clear that Ms McEneaney's rare disease was curable at the time of her presentation, it is likely that her surgery would have been less radical with a better quality of life if her diagnosis was made earlier," it concluded. "Furthermore, her long-term outlook may have been improved and while we cannot state this with certainty her survival may have been prolonged."
A spokeswoman for the HSE said it had met Ms McEneaney's family and continued to update them. She said 31 of 37 recommendations had been completed, five were under way and one, relating to a move to electronic record keeping for patients, was a national issue and had not been implemented. She also said the issue of sanctions was a matter for the Medical Council. Dr Akpan was not available for comment.
