THE family of a child whose wrong kidney was removed said yesterday they had raised concerns a number of times as the child was taken to theatre.

The family, who want to remain anonymous, were speaking after an independent report revealed a litany of errors which led to the child's healthy kidney being removed last April instead of the diseased one.

The report revealed that the child was operated on by an unsupervised junior doctor who had never seen the patient before and had not previously performed similar surgery without being monitored by a senior medic.

The doctor was working from a report of an X-ray carried out on the child six years previously which had incorrectly identified the left kidney as the diseased organ -- even though it was the right kidney which was not functioning.

Other X-rays and scans were carried out in the intervening time, but reports of these investigations which pointed to the correct kidney were missing from the child's file.

However, there are no plans to undertake disciplinary action against anybody over the error.

A spokesman for the health service said that the hospital had full confidence in the staff of Our Lady's Children's Hospital.

"This was a tragic error which we have taken steps to ensure will never happen again. In addition to the independent review, the hospital has made strenuous efforts to seek advice from professional bodies in Ireland and abroad with regard to the full implications of this incident for all the staff involved."

The report, commissioned by at Our Lady's Hospital for Sick Children in Crumlin and carried out by two independent medical experts, also highlighted the long working hours of the junior doctors.

A consultant surgeon incorrectly recommended the removal of the healthy left kidney and the surgery was carried out by a specialist registrar who was not supervised by a senior.

Yesterday, the child's family issued a statement of clarification after the publication of the report .

They said they had raised their concerns about the surgery on several occasions up to and including the time the patient was taken to theatre.

A spokeswoman for the hospital admitted these "concerns were not fully addressed" and that it took "full responsibility "for the tragic error.

She said the child is still in the care of the hospital.

The report also highlighted a previous "near miss" in the hospital seven years earlier when a left kidney was due to be removed. An incision was made on the right side, but the mistake was caught early and the surgery proceeded correctly. The 'near miss' was not formally reported.

In response to the blunder, the Crumlin hospital has introduced a "correct site surgery policy" which addresses a number of the report's recommendations.

The report said 10 factors contributed to the error.

It was compiled by acting assistant director and patient safety and complaints manager Penny Tallents, and Imran Mushtaq, a consultant paediatric urologist at Great Ormond Street Hospital in London.

It noted that "on transfer to the theatre the ward nurse handed over to the receiving nurse a concern expressed by the parents about the site of the surgery.

"The receiving nurse immediately contacted her manager and obtained help from the specialist registrar who came to talk to the parents."

The child was admitted the day before outside normal working hours, and was not seen by one of the consultant's team.

The six-year-old X-ray report, which incorrectly identified the diseased kidney, had not been corrected but it was central in contributing to the blunder.

Formal reports on scans and ultrasounds carried out the in the previous six months confirmed that the abnormal kidney was on the right side, but these were "lost."

The experts' report said the consultant did not have a computer in the clinic room to look up the radiology report -- there is one computer in the nurses' station shared between five clinic rooms.

It also revealed that, although the consultant intended to hold a multidisciplinary meeting on the patient before surgery, this did not take place, and there was no system at the hospital to ensure these are carried out.

The X-rays and scans were also not reviewed during the pre-operative morning round, and are not normally sent to the ward or theatre.

This practice was stopped three years ago in a bid to keep track of X-rays.

It also highlighted the long hours and workload of the specialist registrars. Their average working week was between 73 and 107 hours. The hospital had no "site-marking policy" which would ensure several checks were carried out before surgery to avoid this kind of mistake .

It also highlighted the 'parallel theatre list', which was where several operations take place simultaneously. In this case, the specialist registrar who had a break in surgery went to another theatre and asked the consultant if he could help out.

The consultant asked him if he would like to do the child's surgery, saying it was within his competence, "although he had never performed one completely unsupervised".

The report said it did not "seem unusual for a major case to be handed to a specialist registrar without warning".

- Eilish O'Regan Health Correspondent