Cancer alert caught up in eight-month review delay
X-ray problems were spotted but HSE 'dithered' and patients died
When the Health Service Executive announced a "review", on May 15, of 6,000 chest X-rays and scans taken by a radiologist in Our Lady of Lourdes, Drogheda, and Navan hospitals, the embattled organisation said that, since the matter came to its attention, hospitals were working to ''identify as quickly as possible the nature and extent of the issue''.
But heavily edited documentation, secured under the Freedom of Information Act by the Fine Gael TD Fergus O'Dowd, reveals that it took eight months of ''dithering'' by high-powered directors and advisors before a look-back was even announced.
Speaking to the Sunday Independent, Mr O'Dowd said the documentation provided a ''a frightening portrait of chaotic decision making, internal Chinese walls and a dysfunctional management structure'' at the HSE.
The story begins on September 12, 2007, when Dr John Kiely sent a letter about two cases of X-ray findings involving apparent missed lung cancer to a consultant colleague, Dr Paul Keelan. This was promptly forwarded to management at Louth Hospitals. The X-ray findings had been made by a locum doctor.
The discovery of ''significant abnormalities'' on two patient's chart, which had previously been ''reported as normal'', would appear to warrant a full-scale emergency response. But a month later, management at Louth Hospitals was still seeking ''an opportunity to discuss how we can carry out an audit on a wider sample of this radiologist's work''.
By October 31, six weeks after the consultants expressed their concerns, a second letter from Louth Hospitals management to the HSE reveals that they were only planning to meet to ''discuss the structure of an audit''.
At that point, Louth Hospitals management wrote to the HSE ''requesting'' that an audit might commence and that it would be confined to ''possibly 200-300 X rays''. Three weeks later, there was no sign of any review.
The state of play was captured by a panicky e-mail, after November 22, from a senior HSE bureaucrat -- asking whether Louth Hospitals knew where the locum involved was now working, if any alert had gone out and whether the Medical Council had been informed. Subsequent e-mail traffic indicates a voicemail message was left with the council.
HEALTH JOB CUTS LOOMING, PAGE 5
A December 12 e-mail reveals the HSE had made no final decision on ''how the review should proceed'', although all network managers had been contacted regarding the locum and the correspondence copied to the medical council.
By December 19, senior regional management had finally approved a review. By January 14, hospitals were looking for ''technical advice on randomisation and sampling''.
On the February 27, Louth Hospital management informed senior regional management that "the review has not taken place primarily due to ongoing discussions about the methodology''.
There had also been a need to ''contact the Medical Protection Society for advice'' about insurance issues. Six months into the affair, no patients had been contacted -- but concerns were expressed about the ''impact on the clerical staff'' of a review.
Something began to stir after March 10, when the new Health Information and Quality Authority (HIQUA) wrote to the National Hospitals Office. In an letter which was written six months after the crisis first broke, the HIQUA asked whether the locum radiologist was still working for the HSE, for details on "any review the HSE has commenced or will be commencing'' and whether ''consideration is being given to communicating with patients.''
The involvement of the senior figures in the HSE -- the letter was also copied to Brendan Drumm -- appears to have been the catalyst for a change in the atmosphere.
By mid-March, in a memo called 'Actions from a meeting', for the first time there is a decision, in print, to ''ensure individuals who are maybe affected by any adverse incident are informed in a timely way''.
It was then finally decided ''that in view of the politics of the situation a full scale review was required'', although concern was expressed as to ''where do we send expense claims''. In spite of the new interest from the top the situation remained chaotic.
Subsequent e-mails reveal that HSE bureaucrats didn't know if an external review meant bringing in an international expert, while it was noted that ''costs could be substantially lower if the HSE gets someone from Dublin''.
By March 28, an e-mail from Louth Hospitals management reveals that the HSE had decided to ''progress this review as a matter of urgency''.
In spite of this decision, a further six weeks passed before the HSE finally announced its review -- eight months after the problem was spotted.
The HSE hopes to publish "the full report" in September -- a full year later.
Meanwhile, four of six patients whose x-ray results were misdiagnosed have died from lung cancer.
- JOHN DRENNAN
