Ban for scan doctor but no justice for families

Simon Brouder & Sinead Kelleher

The doctor whose work was at the centre of a major review of suspect scans at University Hospital Kerry has been suspended from practising medicine in the Republic of Ireland by order of the Hight Court.

The court’s decision comes less than a week after the HSE published the findings of its comprehensive ‘look back’ review of all scans examined by a locum radiologist who had been temporarily employed at the hospital but who no longer works there.

The scan crisis began in July and August 2017 when management at the hospital were notified of three missed cancer diagnoses that had not been picked up by the locum. The radiologist was immediately placed on administrative leave and a preliminary audit of her work was carried out.

Based on the results of that audit it was decided to carry out a re-check of every single scan the radiologist had examined while employed at the hospital. This saw the review team examine 46,234 individual scans, x-rays and ultrasounds relating to 26,754 individual patients.

At a press conference in Tralee last week representatives of the HSE South/South West Hospital Group presented the findings of the review, the largest of its kind ever carried out in the state.

It was found that 11 patients, including 10 with cancer or serious cancer related illnesses, suffered a delayed diagnosis due to hospital x-ray and scan failures. Four of the patients have since died.

“Regrettably four of the eleven patients have passed away in the intervening time period between identifying their delay and the publication of the lookback report,” said the HSE.

“The delayed diagnoses has had a negative impact on their clinical course. With regard to timings afterwards, it is difficult to say for sure, but everyone knows that the earlier the diagnosis is made and acted upon is always better for the patient and, unfortunately, this did negatively affect their clinical course,” Dr Claire O’Brien told the press conference.

The peer review audit was grouped into three categories, Score 1, Score 2, and Score 3. 44,831 were given a Score 1 where nothing of significance was found. 1,298 were given a Score 2. This related to an unreported finding that was unlikely to be of clinical significance 105 were given a Score 3. This required immediate communication to a Clinical Subgroup as the previously unreported finding was of potential concern.

“I would like to thank the patients and their families for the courtesy and understanding shown by them to the hospital staff in the course of this review. This cannot have been easy particularly when having to deal with devastating news which would have had a profound effect on them and their families,” said Dr Gerard O’Callaghan who chaired the Safety Incident Management Team (SIMT) that conducted the review.

At the press conference the HSE apologised “sincerely and unreservedly” to all patients and families “harmed” by the “delayed” diagnoses.

On Monday, the High Court granted an application by the Medical Council to suspend the locum radiologist at the centre of the crisis.

Mr Justice Peter Kelly said he was satisfied it was necessary, on public interest grounds, to grant the Medical Council’s ex parte application (one side only represented) for the order against Dr Clare Hartigan, with an address at Ballinwear, Nenagh, Co Tipperary, who had worked at the Kerry hospital between March 2016 and October 2017.

The court heard that the council had decided last week – following a meeting attended by Dr Hartigan – to make a complaint to the Preliminary Proceedings Committee on grounds of a relevant medical disability under the Medical Practitioners Act 2007 and to seek to have her suspended from practice.

The council said its reasons included its view Dr Hartigan had a lack of insight into her mental health issues; had failed to engage with the council and had refused an assessment by an independent psychiatrist.

The council was concerned about Dr Hartigan’s health and welfare, believed that she had impaired judgement and that there was a risk to patients if she continued to work without appropriate assessment.

The judge said the council was “rightly concerned” about Dr Hartigan’s lack of insight into her current condition and about her ability to make judgments.

Mr Justice Kelly noted the manager of the Kerry hospital had complained in October 2017, alleging Dr Hartigan had failed to meet the standards of competence that could reasonably be expected of a consultant radiologist in the performance, carrying out and reporting of radiological examinations.

That complaint – made when the look back review was in its early stages and was far from completion – alleged that there were three known serious reportable events where the diagnostic error had led to serious harm to patients and about 30 incidents where Dr Hartigan’s practice was less than the standard required and potentially could have harmed a patient.

The court was told that a serious incident management team (SIMT) was established and a decision was made to review all radiological imagery performed and reported on by Dr Hartigan, who resigned her post at the hospital effective from October 18, 2017, without any formal disciplinary process.

Mr Justice Kelly heard that Dr Hartigan had disputed the complaints and also had referred to the average workload at the hospital of 75,000 scans per year.

She said that she had completed 37,000 scan examinations in one year, which would represent half of the total average workload for the were five radiologists typically employed at UHK.

The court was also told that a report prepared by the SIMT said the team did not wish to imply any harm was attributable to Dr Hartigan.