EXTERNAL REPORT ON COLONOSCOPY FAILURES AT WEXFORD WORRIES RAISED
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.