The full details of who knew what and when regarding the review of ultrasound scans on women with suspected breast cancer at the Midland Regional Hospital in Portlaoise will not be known until a report by the board of the Health Service Executive (HSE) is finalised, writes Martin Wall
However, the preliminary indications are that there was a complete failure of communication within the HSE and also between it and the Department of Health.
The HSE announced in late August that it was to conduct a review of all breast diagnostic services including mammography and ultrasounds at the hospital between November 2003 and August 2007.
The terms of reference were drawn up by the HSE and subsequently agreed by officials in the Department of Health.
The review of mammograms was carried out by Dr Ann O'Doherty, a specialist breast radiologist. However, the Department of Health maintained that it believed the ultrasound review was also to be carried out under the auspices of Dr O'Doherty and that there was just one report.
Minister for Health Mary Harney told the Dáil on November 7th that Dr O'Doherty "has been asked to look over the mammograms, ultrasounds and anything else that is relevant, including the machinery".
However, it appears that the HSE in the midlands had in early September asked a consultant surgeon in Portlaoise, Peter Naughton, to review the clinical notes of hundreds of patients who had ultrasound procedures for suspected breast cancer from August 2005 to August 2007.
Unlike mammograms there are no hard copy films arising from ultrasound procedures which can be stored and later re-examined.
Mr Naughton reviewed the case notes of 568 women. Concerns were found in relation to 97 cases initially and these women are to be referred for further surgical review and possible further radiological assessment.
Department of Health sources said Dr O'Doherty provided regular progress reports to the HSE on her mammography review which found that nine women who had been given the all-clear actually had breast cancer.
Department sources maintained that in all the briefings provided to it by the HSE in relation to the Portlaoise review, it was never given any indication there was a parallel process under way looking at ultrasounds.
The Department of Health believed that the ultrasound component of the review had been incorporated into Dr O'Doherty's findings on mammography.
It is unclear whether the HSE had actually approached Dr O'Doherty regarding a specific review of ultrasounds.
Meanwhile, it appears that confusion also reigned within the structures of the HSE. It appears that Mr Naughton's involvement stemmed from a meeting with local HSE administrators in the midlands in early September at which he was asked to carry out a review of the clinical notes.
However, it is unclear whether the HSE in the midlands had informed the National Hospitals Office centrally about the Naughton review.
Alarm bells regarding the ultrasound review began to ring on Wednesday morning when Ms Harney was preparing to answer parliamentary questions about Portlaoise. Department sources said that there was some vague reference by the HSE National Hospitals Office about a second review which was later confirmed in an e-mail.
The Minister did not mention the ultrasound review in the Dáil and afterwards her secretary general, Michael Scanlan, asked HSE chief Brendan Drumm about it. Prof Drumm said he had no knowledge of this review.
On Thursday morning both Ms Harney and Prof Drumm were to appear before the Oireachtas Health Committee where the issue was likely to be raised again. Department sources said the Minister met with the HSE chief beforehand and he told her that National Hospitals Office director John O'Brien would deal with the issues. Ms Harney has said that the first she knew of 97 women being recalled was when Mr O'Brien spoke.
The issues involved in the controversy are very serious both for the HSE and the Government's overall healthcare reforms. A key criticism of the health board system was that the different regions were effectively independent fiefdoms. The HSE was designed as a national body. Local initiatives taken without the knowledge of central management were not part of the plan.