Missing reports a major factor in error
Published 03/09/2010 | 05:00
Surgeon Martin Corbally has been a doctor for 30 years and gained his medical degree from University College Galway.
He later graduated from the Royal College of Surgeons and specialised in paediatric surgery, paving the way for a full-time consultant's post at Our Lady's Hospital for Sick Children in Crumlin.
Now in his 50s, he is associate professor of surgery at the hospital, which leaves him dividing his time between clinical practice and the Royal College of Surgeons. He lives in Dublin 12, which is close to the hospital.
Back in 1992 he made the news when he assisted in some of the first liver transplants in Ireland. He was on the team to operate on children in Crumlin, while adults were referred to St Vincent's Hospital.
Five years ago he was part of a medical team that travelled to Vietnam as part of the Christina Noble Foundation. The team visited Ho Chi Minh City to carry out complex surgery on children with bowel disorders.
A report on the case for which he is now before the Fitness to Practise inquiry found he had listed the wrong kidney for removal.
A major error in X-ray reporting some years prior to the surgery on the boy, which remained uncorrected, was a significant contributory factor in the later blunder.
The inquiry cited the incorrect X-ray report, a lack of multidisciplinary discussion of the operation, junior doctors' hours and workload and flaws in X-ray reporting procedures as contributing to the tragedy. It found that key reports on scans confirming the child had a right-sided abnormality went missing from the medical records.
It said many of the clinicians interviewed believed that the heavy caseload for the hospital's general surgery team was a root cause of the incident.
The inquiry recommended that general surgeons should introduce team briefings before each theatre list where the patients would be reviewed. There should be a "surgical pause" at the beginning of each case, it said.