Urgent action is required to restore faith in the North Eastern Health Board, argues Dr Muiris Houston, Medical Correspondent
The death of nine-year-old Frances Sheridan, following treatment for acute appendicitis in Cavan General Hospital, has once again focused attention on the quality of healthcare in the North Eastern Health Board (NEHB) region.
The Board is no stranger to controversy. In December 2002, baby Bronagh Livingstone died following her premature birth in an ambulance while travelling between Monaghan and Cavan hospitals. This tragedy followed the closure of the maternity unit in Monaghan, amid warnings by local politicians and community leaders predicting just such an event.
At the time, the main focus of concern was Monaghan hospital, where the NEHB has cut back on accident and emergency and other facilities as part of its plan to concentrate services at two main hospitals in the region. Its long-term strategy for the area has always been to focus acute services in Our Lady of Lourdes Hospital, Drogheda and in Cavan General Hospital. It talked about the "Cavan/Monaghan" group of hospitals and a "Drogheda/Dundalk/Navan" conglomeration.
Under the circumstances, it was reasonable to presume that Cavan hospital would have its services copper-fastened in order to take the pressure from Monaghan as well as Co Cavan. Cavan hospital was rebuilt and additional consultants and ancillary staff put in place in surgery, medicine and anaesthetics.
However, as soon as Monaghan was downgraded and Cavan took on the extra workload, it began to creak at the seams. GPs and consultants have told The Irish Times of long waiting times in accident and emergency: patients were spending long periods on trolleys while the hospital struggled to find room for them "in-house".
The hospital might have been in a better position to cope with this were it not for an ongoing row between two consultant surgeons at Cavan General.
William Joyce and Pawan Rajpal were having what the health board subsequently referred to as "interpersonal difficulties". Because these difficulties involved two-thirds of the surgical consultant complement in Cavan, it immediately placed enormous pressure on all staff in the hospital.
A consultant surgeon's remit extends from accident and emergency to the operating theatre, and from outpatients to the surgical wards. Anaesthetists and pathologists work closely with surgeons, so there was scarcely a department within the hospital unaffected to some degree by the row.
Such was the gravity of the situation, the Chief Medical Adviser to the NEHB, Finbar Lennon, wrote to the CEO, Paul Robinson in January 2003 to outline his concerns about the Cavan surgical unit.
"Serious questions have been raised within the unit itself and within other hospital departments (anaesthesia and pathology)", he wrote. Lennon identified peer conflict as being "very damaging" to the surgical unit.
Eventually, in August last year, the NEHB suspended Rajpal and Joyce because of their interpersonal difficulties. Both have gone to the High Court to have their suspensions lifted.
With only one remaining permanent consultant in post - who has been off work for health reasons - the NEHB faced a dilemma. It needed to recruit three locum surgical consultants, but could not offer long-term contracts because of the uncertain nature of the periods to be filled. The surgical unit was also left without a senior figure to head the department.
It was against this background that Frances Sheridan died following an operation for acute appendicitis. There has also been an allegation that another child was sent home from Cavan General, only for a perforated appendix to be subsequently diagnosed at a separate hospital. However, it must be emphasised that the accurate diagnosis of acute appendicitis and its complications is one of the trickiest challenges in clinical medicine (see panel).
In an article published in The Irish Times in December 2002, Robinson said of proposals for the development of hospital services in the north east, that they "are based on looking after the patient first . . . in an environment which on current authoritative medical evidence, maximises the prospect of optimum outcome".
In the light of recent events, the prospects for optimal patient outcome at Cavan General do not look good. GPs are referring patients for treatment as far away as Sligo and Dublin rather than expose them to the current uncertainties in Cavan.
What we are now seeing is a loss of confidence in its services by people living in two of the four counties that make up the NEHB.
The domino effect has been to place additional pressure on services in the North Western Health Board and in the Eastern Regional Health Authority.
How long can the Minister for Health, Micheál Martin, allow this to continue?
While he may be tempted to await the reform of the health service that he has initiated, that would be unwise. The responsibility for the day-to-day running of the North Eastern Health Board should be taken over by the Department of Health before hospital services in the region deteriorate even more.