Sorry is welcome but assurances are better

MANAGEMENT at Kerry University Hospital have clearly learned some lessons from the CervicalCheck scandal. Most importantly, they were quick to offer profuse, unreserved and plainly heartfelt apologies to all those affected by the misreading of cancer scans at the hospital.

They also made clear that the locum doctor at the centre of the case had been referred to the Medical Council.

It cannot be overstated how important it is to the public to know that there may be consequences if it emerges that there were unacceptable failings by any individual.

Nevertheless, disturbing questions remain. The review chose not to examine whether the level of misreading was outside accepted norms.

Thus we do not know where ultimate responsibility lies. Was it an individual? Was it a system which failed to support and monitor people reading scans? Or a combination of both?

What we do know is that the report has made recommendations for the future. These include better deliberation of workload for individuals, as well as better performance monitoring.

It is hard not to infer that these safeguards were absent before. And so the question to be asked is, why not? In a world where we know that humans will make mistakes, the key to patient safety must lie in having effective systems to support and oversee the work of individuals.

We need to know whether appropriate systems were in place to catch mistakes before they became dangerous or, in some cases, fatal.

Out of 11 cases identified, four people have died and the other seven have seen serious consequences for their health.

The apology is very welcome, without doubt, but for the sake of the patients affected, and all who attend the hospital, there must be cast-iron assurances that better systems will be initiated to ensure forensic oversight of all radiology scans so there is no repeat of this tragic situation.