Eilish O'Regan: 'Review is catalogue of tragedy in scan failure'
The review of scans overseen by a locum radiologist at University Hospital Kerry over 16 months reads like another catalogue of tragedy for 11 patients whose cancers were missed - four of whom are now dead.
While the review was thorough, the report from the South/South West Hospital Group, which includes the Kerry hospital, is very unsatisfactory.
It is particularly short on analysis of what went wrong.
The work of one locum radiologist was examined.
But this was not prompted by an internal audit at the hospital. It followed the return of several patients over the summer of 2017 who had scans and were referred back by their vigilant GPs.
It was only on foot of these cases that alarm bells rang. It was decided to do a look-back at more than 40,000 scans and X-rays by the consultant radiologist who was involved in the diagnostic procedures.
The report published yesterday throws little light on what led to the failures. It points to a large volume of work carried out by the doctor. Was this self-imposed or due to the demands on the radiology department?
The report said there were no national or international guidelines indicating the volume of work to be performed by individual radiologists.
There were also hints about the radiologist's work that raised red flags before the errors came to light in 2017. The report refers to a number of ultrasounds that were of poor technical quality. It does not say what happened on foot of these concerns.
Was the doctor spoken to? Was some form of monitoring and checks put in place? The recruitment procedures do not seem to be at fault and it is understood the doctor in question had a particularly impressive CV.
There are good and comprehensive recommendations in the report which may have implications for radiology departments in other regional hospitals, also. They include the appointment of a radiologist who is given time for peer review and performance monitoring.