Wexford General says it ‘deeply
KEN MEALY, Wexford General Hospital’s Consultant Surgeon and Clinical Lead, said the hospital ‘deeply regrets this incident’.
‘Since notification of the first cancer case, our priority at all times has been to conduct a thorough and immediate review,’ he said in a statement.
‘Our first action was to identify, recall and treat all patients who may have been affected. We have worked with BowelScreen to strengthen governance procedures around this incident and shared our learnings, with a view to ensuring that this never happens again.’
A summary of the HSE review of the screening errors says in that October 2014, Wexford General Hospital identified two cancer cases in patients who had recently undergone a colonoscopy, but were not diagnosed at that time, and immediately began working with BowelScreen to conduct a thorough and immediate review of colonoscopies under the care of an individual consultant at WGH. He is not identified, and is referred to as Clinician Y throughout the report.
Following a review of both cases, a Safety Incident Management Team (SIMT) drawn from BowelScreen, Wexford General, patient focus representatives, the Ireland East Hospital Group (IEHG) and clinical expertise was established, in line with the HSE’s lookback policy.
All colonoscopy patients under the care of an individual consultant at WGH between March 2013 and November 2014 and their GPs were written to and received a follow-up phone call from liaison staff working within either WGH or BowelScreen. A total of 615 patients were recalled, 401 of whom, following review, were deemed necessary to have a repeat colonoscopy. Over three quarters of recalled patients attended a colonoscopy within a month of being contacted. This process was completed using the clinical pathways within the IEHG, with follow-up colonoscopies carried out at St Vincent’s Hospital in Dublin, the Mater Hospital in Dublin, and Wexford General. In total, 13 cancers were detected, including the two cases that prompted the recall and the case of a deceased gentleman who died before the lookback started. The clinical subgroup of the SIMT for this lookback has categorised all cancers detected as ‘probable missed’. The consultant whose work this review concerns has been on leave since 2015.
Wexford General also began an immediate process of open disclosure with the patients and families concerned and has apologised on behalf of the hospital for any failings in the services provided to them. A copy of the report of this review has been provided to those families and patients.
Assurance measures are in place to ensure all colonoscopy services delivered on behalf of BowelScreen at both Wexford General and all other units are of the highest standards possible.
This process is now complete. The review contains important findings and recommendations which are being implemented.
The HSE is assured that services are operating to a high standard, but given the gravity and scale of this incident, the HSE is commissioning an external expert to review the Quality Assurance measures put in place and the overall management of the incident. Terms of reference for this next process have been agreed and an expert has been identified. This reflective process as the incident concludes is in line with best practice.
The report reveals that the BowelScreen programme was informed on October 8, 2014, of a recently diagnosed case of caecal cancer, who had undergone a screening colonoscopy in April 2013 at Wexford General. The notification was made by the Consultant Surgeon, not attached to Wexford General, who had performed the cancer surgery. In accordance with the MOU between Wexford General and BowelScreen, Wexford General was informed of the case and asked to undertake an immediate case review.
A second case of caecal cancer in a