A shortage of consultant radiologists and an inadequate response by management to well flagged problems at Tallaght Hospital were among a range of factors which led to nearly 58,000 x-rays being left to go unreported at the hospital, an independent investigation has found.
The report of the investigation chaired by Dr Maurice Hayes and published this afternoon found there was also an absence of written policies and protocols at the hospital setting out categories of X-rays which did not require to be read by a consultant radiologist.
There were difficulties too with the hospital's radiology IT systems, and there were persistent problems with the typing of x-ray reports which contributed significantly to the backlog.
The backlog of 57,921 X-rays came to light last March after the hospital disclosed two patients, one of whom had died, had a delayed diagnosis.
All the X-rays have now been reviewed and "no untoward event, no missed diagnosis and no undetected condition" was found. "This is a strong indicator that the X-rays had been competently reviewed at the time, even if not reported on," the report says.
It says consultants flagged their concerns about backlogs to hospital management on more than 30 occasions between 2005 and 2009.
"There was a shortage of consultant radiologists. The existing workload when compared to an internationally validated model demonstrates that the workload is high when compared to two other Dublin teaching hospitals or to Australian norms. Responsibility for this must be shared by the hospital for not adequately prioritising or vigorously pursuing additional consultant appointments, and by the HSE (and its predecessor bodies) for not approving posts in a reasonable and timely manner," it says.
New guidelines were recently circulated indicating not all x-rays have to be reported on by radiologists. But even if these guidelines had been in place in Tallaght some 26,275 of the unreported X-rays would still have had to have been reported on, the report states.
In March it also came to light that thousands of GP referral letters may have remained unopened at Tallaght hospital. The inquiry also looked at this issue and found more than 3,400 GP referral letters were not dealt with appropriately but no letters were "unopened".
Some 97 per cent of the patients named in these GP referral letters have now been seen by a consultant and the remaining 157 have been offered appointments at the hospital.
Again the report says the absence of a clear policy or written procedures and protocols for dealing with outpatient referrals from GPs was one of the main reasons for the letters remaining unprocessed.
Many of the letters were for orthopaedic outpatient appointments and "a dispute between hospital management and orthopaedic consultants about the failure to ring fence beds required for elective surgery, and the sacrifice of dedicated orthopaedic beds to meet the pressure of emergency admissions" also contributed. There was also "the inability of the hospital to resolve this issue over a long period".
Both problems - with the X-rays and GP referral letters - were symptomatic of wider problems at management and hospital board level, the report adds. "There were severe systemic and other weaknesses at management level, and the structures at board level were simply not robust enough to provide the level of governance, supervision and direction required in the management of a large and complex organisation".
The hospital, which had a 23 member board of management, says the board has now been slimmed down. It has undertaken to implement the report, as has the HSE. The report recommended GP representation on the board of management and this will now be considered.
Dr Hayes said no case of medical malpractice had been identified.
Overall he said there was confusion over the numbers of x-rays which had backed up over a long period, there was confusion over reporting relationships and he didn't believe any one individual was responsible for what happened.
The HSE said it has now approved funding for two additional consultant radiologist posts at Tallaght Hospital.
Labour TD Pat Rabbitte said this evening the report "shone a welcome light on the workings of the hospital and the HSE."
"it is clear from this report that the hospital has been failed by a HSE that has ignored the urgent needs of Tallaght, and that as a result, the safety of patients has been put in jeopardy," he said.
He called for the post of chief executive at the hospital to be filled without delay.