EX­TER­NAL RE­PORT ON COLONOSCOPY FAIL­URES AT WEX­FORD WOR­RIES RAISED

Gorey Guardian - - NEWS - DAVID TUCKER

IT TOOK MORE than 18 months from the time con­cerns were first raised about the per­for­mance of a doc­tor car­ry­ing out in­va­sive pro­ce­dures at Wex­ford Gen­eral Hospi­tal un­til the clin­i­cian ac­tu­ally stopped car­ry­ing out screen­ing colono­scopies.

The warn­ings amounted to a ‘missed op­por­tu­nity’, with a newly-pub­lished ex­ter­nal re­view say­ing there was no doubt the doc­tor was ‘un­der-per­form­ing’.

Wor­ries about the per­for­mance of the doc­tor car­ry­ing out the tests were raised five times by another mem­ber of staff, how­ever, no im­me­di­ate ac­tion was taken.

Fol­low­ing a re­call of more than 400 peo­ple it was found that 13 pa­tients were wrongly given the all-clear fol­low­ing the rou­tine colono­scopies.

A sep­a­rate re­view last year re­vealed the 13 pa­tients, tak­ing part in the na­tional bowel screen­ing pro­gramme for peo­ple aged 60 to 69. Two of the 13 have since died.

The ex­ter­nal re­port, pub­lished last week, found a HSE mem­ber of staff first raised con­cerns about the doc­tor in March-April of 2013. More than a year later, in Septem­ber 2014, a pa­tient who had un­der­gone a screen­ing colonoscopy at the hospi­tal in April 2013 was found to have can­cer. Bow­elScreen was told of this in Oc­to­ber 2014.

A sec­ond case emerged in late Oc­to­ber 2014 and Bow­elScreen was also no­ti­fied, with the first phase of the re­call of pa­tients be­gin­ning in Jan­uary, 2015.

The ex­ter­nal re­view of how the HSE man­aged the se­ri­ous in­ci­dent of 13 prob­a­ble missed can­cers at the hospi­tal found that there were missed early op­por­tu­ni­ties in re­spond­ing to a staff mem­ber’s con­cerns over the stan­dards of an in­di­vid­ual clin­i­cian’s work there. The 24-page re­view pub­lished by the HSE was con­ducted by Pro­fes­sor Robert J C Steele, se­nior re­search pro­fes­sor preven­tion, early de­tec­tion and treat­ment of col­orec­tal can­cer, at the Univer­sity of Dundee.

Prof Steele says the orig­i­nal re­view was car­ried out in a timely and ef­fi­cient man­ner and to the high­est pos­si­ble stan­dards.

In the re­view, Pro­fes­sor Steele says that in March-April 2013, soon af­ter Wex­ford Gen­eral Hospi­tal be­gan do­ing screen­ing colono­scopies, a HSE em­ployee ex­pressed con­cern to the clin­i­cian, re­ferred to as Clin­i­cian Y, about the in­di­vid­ual’s work.

In May 2013, the staff mem­ber ex­pressed those con­cerns to Bow­elScreen by tele­phone ‘and was re­as­sured that the con­cerns would be com­mu­ni­cated to the Clin­i­cal Lead’ at Wex­ford.

A con­ver­sa­tion took place be­tween the Clin­i­cal Lead at Bow­elScreen and the Clin­i­cal Lead at Wex­ford.

In June 2013, when the HSE em­ployee saw no im­prove­ment in the work of Clin­i­cian Y, the staff mem­ber com­mu­ni­cated con­cerns ver­bally to the Clin­i­cal Lead at Wex­ford.

The Clin­i­cal Lead spoke to other staff, who did not raise con­cerns.

In March 2014, the Clin­i­cal Lead at Wex­ford asked the HSE em­ployee to doc­u­ment the con­cerns about Clin­i­cian Y.

In Novem­ber 2014, it was agreed be­tween Clin­i­cian Y, Wex­ford Hospi­tal and Bow­elScreen, that the clin­i­cian would stop car­ry­ing out screen­ing colono­scopies, pend­ing case re­views.

Clin­i­cian Y ceased all colono­scopies on Fe­bru­ary 16, 2015, by mu­tual agree­ment with the hospi­tal.

The re­port says the clin­i­cian par­tic­i­pated and co­op­er­ated with ev­ery­one work­ing on the man­age­ment of the in­ci­dent.

Clin­i­cian Y went on leave in 2015, and has sub­se­quently un­der­gone re­train­ing in colonoscopy but has not re­turned to work.

Prof Steele said that, while recog­nis­ing the sig­nif­i­cant ef­fect of the in­ci­dent for pa­tients and fam­i­lies af­fected, the bowel screen­ing team has learned a great deal to the ben­e­fit of the bowel screen­ing pro­gramme in Ire­land.

Wex­ford Gen­eral is a colonoscopy provider unit, as part of the Bow­elScreen pro­gramme na­tion­ally.

The HSE has said that in re­sponse to this find­ing, Bow­elScreen has im­ple­mented a new pol­icy to man­age safety in­ci­dents in a stan­dard­ised and ap­pro­pri­ate man­ner.

Bow­elScreen be­gan in Oc­to­ber 2012 and of­fers free screen­ing to men and women aged 60-69, on a two-year cy­cle.

To date, more than 488,600 peo­ple na­tion­wide have been in­vited for screen­ing.

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