A family who lost their father to bowel cancer - after he was wrongly given the all-clear - spoke of their heartbreak yesterday after an investigation revealed the blunder may have been picked up earlier.
Pat Fitzpatrick (73) was one of 13 patients whose cancer was missed by a doctor at Wexford General Hospital.
An external review revealed yesterday that despite repeated alerts by a member of staff no action to recall patients was taken for a year.
Dee Fitzpatrick, from Co Wexford, whose father died last April, said yesterday the outcome may have been different if concerns about the doctor carrying out the colonoscopy procedure, an invasive diagnostic test, were acted on earlier.
"Dad had a colonoscopy in February 2013 following symptoms of bowel cancer. In March to April 2013, a HSE employee in the hospital expressed concern to the consultant about his completion of colonoscopies.
"This brave worker highlighted issues with the consultant on five occasions both to the hospital and BowelScreen. They asked for an audit of photos but this did not happen."
Professor Robert Steele carried out an external audit
Mr Fitzpatrick had been given the all-clear, but when he complained of feeling unwell two years later and had a repeat test the bowel cancer was confirmed.
The family believed all facts were disclosed, but found out about the staff member's concerns only yesterday.
"This is another emotional blow for the family," she said.
The information emerged in the external audit carried out by Dundee University expert, Prof Robert Steele, who said failure to follow up on the concern was a "missed opportunity".
It emerged in January last year that a review of 615 cases and recall of patients found 13 probable cancers were missed by the one doctor.
They were participating in BowelScreen, the national bowel screening programme for people aged 60 to 69.
It later emerged that one patient died before the review, covering the period March 2013 to November 2014.
The doctor went on leave in 2015, but no longer performs the procedure.
The cancers were probably missed during the original test. A recall involved 615 patients at Wexford General Hospital in 2013 and 2014. Six of the patients were from Wexford, and seven from Carlow-Kilkenny.
Prof Steele said the look-back was carried out efficiently. Budget constraints hampered regular performance audits by BowelScreen.
The HSE said in response that BowelScreen had implemented a new policy to manage safety incidents.
BowelScreen has also developed enhanced policies and procedures to strengthen early warning systems and to ensure that a proactive response is taken in all cases where concern is raised by staff.
Commenting on the report, the Irish Cancer Society said: "There is a need for staff concerns to be listened to and followed up in a timely manner.
"There is a need for more oversight, reporting and quality assurance guidelines to prevent another such incident."
It added that there are "clear learnings for both BowelScreen and our endoscopy services outlined in the report".
But it wanted to assure people that "BowelScreen has taken steps to ensure an incident like this doesn't happen again and the Irish Cancer Society has full faith in a service that saves lives".
In its first round completed in 2015, BowelScreen detected 517 cancers, almost three in four of which were at an early stage.