The family of a child who had a healthy kidney removed in error at Our Lady's Hospital for Children Crumlin said today they had raised concerns about their child's surgery "on a number of occasions" up to the operation and that these concerns were not addressed.
The Crumlin hospital commissioned an independent inquiry in April after it admitted “a significant and regrettable medical error” in removing the child’s healthy kidney, instead of the diseased one.
In a statement issued by the hospital this afternoon, the hospital said that it and the family "wish to clarify to the media that the family did raise concerns about their child's surgery, on a number of occasions, up to and including the time of handover to theatre".
"These concerns were not fully addressed by the hospital and Our Lady's takes full responsibility for this tragic error," the statement said.
The review carried out at Great Ormond Street Hospital for Children in London, a centre of excellence for specialist children's healthcare, has found eight “root causes” of the incident, including delays in filing hard-copy X-ray reports in medical records.
It made eight recommendations, including that the hospital formally monitor junior doctors’ surgical hours in accordance with the European Working Time Directive.
The review team at Great Ormond Street noted that many of the clinicians interviewed at the Crumlin hospital felt that the heavy caseload of the general surgery team, considered against the number of paediatric surgeons in the hospital, was a root cause of the error.
Eight recommendations are made in the report, including that the hospital should review its radiology systems with a view to introducing an electronic system to store radiological images.
It found a number of contributory factors in the surgical error, including the failure to identify an incorrect medical report on the child’s kidney problems six years earlier.
The review recommends that the general surgeons introduce team briefings at the outset of each theatre list, and that the hospital should ensure that risk-management processes are “embedded” within clinical teams.
It notes that a detailed plan will be needed, including an audit programme that can “deliver sensitive measures of progress and also any barriers to change”.
The review team at Great Ormond Street said it had not proposed implementation plans as it will be important for the senior clinical and managerial staff at OLCHC to review the recommendations within the hospital.
“Some elements of the report may require wider discussion with external agencies,” it says.
The review team said OLCHC had been “extremely supportive” of the review at the most senior level and that it had “proactively shared information and analysis of the events”.
“It was clear from the outset that the hospital was keen to learn from this incident and had begun work immediately to identify system changes. All staff were open and responsive to the review team’s questions, and must be thanked and commended for this.”
The report also noted that the parents of the child involved had commented that care in the hospital since the incident had been “second to none”.
In a statement, the hospital said the report had been given to the family and that it took “full responsibility for this tragic error and once again apologises most sincerely to the child and family”.
“The hospital continues to provide the family with support. The family has chosen to continue to have their child cared for at Our Lady’s.”
It said the board of directors had accepted all the recommendations made in the report and would ensure that they were implemented.
The authors of the independent review were Penny Tallents, acting assistant director/patient safety and complaints manager, and Imran Mushtaq, consultant paediatric urologist at Great Ormond Street Hospital.
It has been published on the website of Our Lady's Hospital Crumlin.