Apology for ‘systemic failure’ from
THE Clinical Lead doctor over colonoscopies at Wexford General Hospital has apologised for what he describes as a ‘systemic failure’ which led to 13 cancer cases being missed, saying that he does not believe the 18 month time lag in which the clinician responsible for the errors remained practising could have been shortened, if he were to have the time over to decide again.
Concerns about the performance of the doctor carrying out the tests were raised five times by a member of staff at the hospital in 2013.
Dr Ken Mealy, Clinical Lead, said: ‘Once we had objective evidence in September and October 2014 we did a very significant review of the practice on these individual’s bowel screening colonscopies. This is when a serious incident management team was set up which was carried out very efficiently, as stated in Dr Steele’s report.’
He said he carried out an internal review in June 2013 looking at the practise in colonscopies at Wexford General. ‘That review involved talking to all of the individuals in the department looking at Key Performance Indicators, which were all satisfactory and within the national parameters – so we felt we had carried out the appropriate review. Retrospectively one may think otherwise, but that was the information available to us at the time. We looked at the documentation of training for that consultant which was appropriate. There was a review of all the other staff members and there was a review of the current work of that individual at that time.’
Dr Mealy said it wasn’t until two patients came forward in the autumn of 2014 that there was ‘objective evidence’ to act on regarding missed diagnoses. The BowelCancer programme was in its early stages having only been introduced months earlier.
He said: ‘It is very difficult to be clear how these tumours grow over any time-scale, but we will presume that these tumours were smaller at the time of the original colonscopy and missed, or perhaps the colonoscopy technique wasn’t extensive enough to find tumours that were at the far end of the bowel. We think it was a combination of both of these (factors).’
He said part of the problem arose from a ‘systems failure’. ‘The checks and balances put in place were not robust enough. If I had to go through the process again with the procesing standard that we had at that time I cannot say I would do anything differently.’
Dr Mealy said the colonscopy consultant had better training than he had in colonoscopies, adding that he did not have oversight over any consultant colleague’s work. ‘Two patients have died and yet again we apologise to all patients and their families. We have done that and we have carried out an open disclosures process. We have to be big enough to put up our hands and say yes we are very sorry that there have been