SO COULD THE MISDIAGNOSED PATIENTS HAVE BEEN SAVED?

Details of four deaths emerge after hospital scan errors revealed

QUESTIONS were raised last night about whether four people who died after delayed cancer diagnoses could have been saved.

Details of the deaths were revealed yesterday after errors were discovered in scans associated with an individual radiologist at University Hospital Kerry.

The resulting review of scans relating to more than 26,000 patients, which the radiologist had worked on, revealed the treatment of 11 people was seriously compromised as a result of the errors. Four of these have died. Between March

2016 and July 2017, the radiologist in question – a locum consultant – alone provided reports on 46,234 images.

Speaking about the revelations, Tralee-based Sinn Féin councillor Toiréasa Ferris said last night: ‘I have been told concerns were repeatedly raised with management about the volume of work this radiologist had to undertake.

‘They raised it as an issue, as did their colleagues. I think if you work it out, the average amount of time they could spend on each report was just under four minutes. That’s a very short space of time to give.’

Cllr Ferris said that given the level of concern raised about the volume of scans the radiologists were reading, ‘you have to ask if these deaths could have been avoided’.

‘And you can be sure the lawyers of the families of those affected will be asking this same question,’ she added.

Staff at South/Southwest Hospital Group (SSWHG) – of which University Hospital Kerry (UHK) is a member – were unable to answer the Irish Daily Mail’s questions about the radiologist’s workload.

However, one of the main recommendations from the group’s review is the need for guidelines about radiologists’ workloads.

The first of three national recommendations from yesterday’s report clearly states: ‘The HSE and Faculty of Radiologists should work to define acceptable volumes of work for individual radiologists.’

The second states: ‘The Faculty of Radiologists should examine how quality improvement programme guidelines can be modified to support smaller hospitals with a reliance on locum radiologists.’

Recommendations for the hospital

‘We need to have a deeper review’

group also include calls for improvements in the peer review process, and ‘performance monitoring for professional staff’.

There are fears that the number of people known to be affected by the errors could increase in the coming months.

This is because 20 of the 422 patients recalled for re-examination following the discovery of diagnostic errors dating back to March 2016 have not been rechecked. Of these, nine cannot be traced.

Although UHK was unable to comment, the Mail understands that of the seven surviving patients whose treatment is known to have been seriously compromised by the errors, at least one has terminal cancer.

Cllr Ferris said she is concerned the number of deaths relating to the controversy could rise further and that she has brought a case not included in the 11 outlined yesterday to management’s attention. ‘They have assured me they are going to look into it and get back to me,’ she said.

Irish Patients Association chairman Stephen McMahon said last night that ‘we need to have a deeper review into how this actually happened’, and that ‘we need to understand if this could have been avoided’.

Fianna Fáil Health spokesman Stephen Donnelly echoed these sentiments, saying: ‘Questions clearly need to be asked, and answered.’ He continued: ‘We really do need to get to the bottom of this and find out if any adverse impacts on patients, including fatalities, [could] have been avoided.’

The review was initiated after management was notified of three serious reportable events, each associated with a diagnostic error, in July and August 2017. As part of the subsequent UHK look-back audit, a review was undertaken of 46,234 CT scans, ultrasound scans and chest X-rays carried out by an individual consultant radiologist, relating to 26,754 patients, between March 2016 and July 2017.

Out of the cases reviewed, 422 patients were identified as needing to be recalled back to UHK.

A South/South West Hospital Group statement issued yesterday said the SSWHG, HSE and UHK ‘would like to apologise sincerely and unreservedly to all patients and families who have been affected by this review’.

It said 11 patients ‘had their diagnosis delayed which had a

‘This cannot have been easy’

serious impact on their health, including the initial three cases which prompted the review’.

The hospital group said four of these have since died, and added: ‘All these cases are the subject of further ongoing system analysis review investigations, which are being shared with individual patients and their families.’

Dr Gerard O’Callaghan, who led the review, said: ‘I would like to thank the patients and their families for the courtesy and understanding shown by them to the hospital staff in the course of this review.

‘This cannot have been easy particularly when having to deal with devastating news which would have had a profound effect on them and their families.’

The report on the review also noted: ‘It is important to emphasise that the outcomes of this review do not wish to imply... that harm done was exclusively contributable to the individual consultant radiologist concerned.

‘There are many factors that influence an individual’s performance.’