A locum consultant radiologist who failed to pick up lung cancer on time in nine patients in the northeast has been referred to the Medical Council of Ireland and the General Medical Council in the UK for investigation.
A review of thousands of chest x-rays and CT scans reported on by him while working at Our Lady of Lourdes Hospital in Drogheda and Our Lady's Hospital, Navan, from August 2006 to August 2007 and published by the HSE today found nine patients had their diagnosis of lung cancer delayed "by some months" as a result of errors he made.
In one case diagnosis was delayed by a year and two months.
The report says eight of these patients have now passed away. One patient "lost a major chance of cure for her cancer".
It says the delayed diagnosis had varying impacts on the care and treatment options of the patients concerned but "included lost opportunities in relation to cure prospects, additional life span and earlier palliative care".
The delayed diagnosis, it adds, led to worry, uncertainty and distress for families and greatly reduced the time available to them to come to terms with the serious diagnosis and the impending death of their family member.
"In the cases where a small chance of cure had been denied, by delayed diagnosis, the families concerned would have the added burden of trying to deal with that very difficult issue. This included the tragic impact on a family whose relative lost a major chance of cure for her cancer," it said.
The review, which was ordered last May, states that the nine cases had been picked up before the look-back commenced.
The review also found 270 patients whose x-rays were read by the locum had had findings on their x-rays which went unreported at the time and while these were "unlikely to have any clinical significance", they should nonetheless have been recorded. These included things such as evidence of old healed TB. These patients have been advised of this and their GPs have been issued with fresh reports on their x-rays.
Overall the review examined 5,835 chest x-rays and 67 CT scans. Some 93 per cent of the patients these related to required no follow up.
In addition 23 barium studies to examine the digestive tract for the presence of ulcers, tumours and other abnormalities were reported on by the locum. Four of these were deemed "incomplete studies" when reviewed and these patients have been referred for further examination. This work is ongoing.
The report was given to the locum, who it is understood now lives in Scotland, for his comments. It is recorded in the report that he has not accepted all the points raised but offered his sincere condolences to all the families and wished to convey his apology for the sorrow and anguish that has been caused as a result of the missed diagnoses.
The HSE said it too wished to apologise to the families of the patients who were harmed by the delayed diagnoses, and to all patients included in the review.
"While the events cannot be reversed, we are unequivocally committed to providing an open and honest record of what happened, and to doing what we can to avoid a recurrence of similar events," it said.
It said it is now enhancing clinical governance in the radiology service in the region to try and reduce the likelihood of errors occurring and increase the likelihood of early detection of those errors which do occur.
Fine Gael health spokesman Dr James Reilly said the review marked the conclusion of “another tragic episode in the health service”.
“Despite some noises from the Minister about locums in the health service, this remains a problem which is not being adequately addressed as, once again, a locum was involved here,” Dr Reilly said.
"An Irish Timesreport from September of this year showed that no references were received by the HSE in respect of one-fifth of the temporary or locum consultants now employed in the northeast region and no interviews were held for a third of the 39 locum consultant positions currently filled in the region.
“Furthermore, the Lynott report on locums, dating back to 2002, was never implemented. The tragic consequences of the Government’s inability to protect patients continue to unfold and yet again the system is seen to protect itself rather than serve the patient.”
Meath East Labour senator Dominic Hannigan said the report’s recommendations outlined must be fully taken on board by the HSE and the Minister.
“If this report does not result in the introduction of safer systems in our hospitals; does not ensure that medics have lifelong competence and does not provide for built-in cast-iron safeguards in our diagnostics systems, then it will have failed,” he said.
Sinn Féin health spokesman Caomghin Ó Caoláin called for a full Dáil debate on the outcome of the review.
“These are very serious conclusions and all the lessons of what occurred must be learned and corrective measures must be implemented and seen to be implemented.”
He also called on the Minister for Health to explain the “exorbitant” €300,000 cost of the review.