Apol­ogy for ‘sys­temic fail­ure’ from

Gorey Guardian - - NEWS - DAVID LOOBY

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

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