To avoid repeat, ten recommendations made
THE UNIDENTIFIED consultant who carried out the procedues is referred to as ‘Clinician Y’. A section of the report details his role at the hospital and his view that the analysis of his work is flawed.
The analysis was updated in September 2015. Based on the identification of 13 cancers, it was estimated that more than 3,000 screening colonoscopies would need to have been undertaken. Clinician Y undertook 384 screening colonoscopies. Clinician Y does not accept this analysis. He has referred to his cancer detection rate of 2.54 per cent, which was within the Key Performance Indicator range.
The HSE report on the incident makes 10 recommendations. They are:
1. The rollout of the National Quality Improvement Programme for Endoscopy should be completed and proceed to mandatory participation for all HSE and HSE funded units
2. BowelScreen should continue to undertake ongoing revision to the Quality Assurance Guidelines and should ensure that the next revision takes into account the findings of this review.
3. The endoscopy service, in association with professional bodies, must develop a competency framework or mechanism.
The Royal College of Physicians of Ireland the Royal College of Surgeons of Ireland and BowelScreen should play a central and leading role in developing such a framework.
Until an appropriate, national framework has been agreed, BowelScreen should continually review and update appropriate methods of assurance regarding
competency in endoscopy from individual endoscopists before participation in the BowelScreen programme.
4. The quality of BowelScreen and symptomaticc endoscopy activity should be audited at unit andd individual endoscopist level. Each unit should be held accountable for local audits. The National Quality Improvement Programme for Endoscopy should have oversight of all endoscopy servicess but the National Shared Services should also have e oversight of BowelScreen audits.
5. The adenoma detection threshold levels shouldld beb reviewedi d in light of this incident
6. Processes should be put in place to ensure timely notification of colorectal cancer in patients who have undergone a screening colonoscopy; this should include a request to all HSE, HSE-funded and private facilities to notify cases and theth establishment of an interval cancer reporting processpr with the NCR.
7. The post-colonoscopy colorectal cancer rate forfo both the screening and general population of IrelandIr should be determined.
8. National Shared Services should develop a specificsp policy for managing safety incidents.
9. The governance of patient and public communication should be clarified by the SIMT from theth outset and adhered to throughout the incident management process, particularly where incidents span different accountability units within the health service
10. All HSE service providers should be continually updated on adverse incident management, notification and escalation processes.