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Report raises new misdiagnosis issues
[Posted: Mon 22/09/2008 by Niall Hunter, Editor www.irishhealth.com]
An unpublished report on the care of Ann Moriarty, who died last April after twice being given the 'all-clear' at Ennis General Hospital is heavily critical of the hospital and raises serious issues about Ms Moriarty's treatment.
The report queries why Ms Moriarty was continually managed at Ennis hospital and not referred on to a specialist cancer unit.
The report is based on an independent review by a multidisciplinary consultant team at University Hospital Galway (UHG).
The HSE used this review, along with a consultation with the Faculty of Radiology, to reach its decision not to initiate an independent inquiry into the Ann Moriarty case.
The HSE had earlier carried out its own internal reports on Ms Moriarty's care which were critical or Ennis hospital. She had also been given an all-clear at St James's Hospital in April 2007 before being tested at Ennis during that summer.
Since this case was reported just over 10 days ago, a further breast cancer misdiagnosis case has emerged, in which a 26-year old woman died after being misdiagnosed at Ennis hospital, and calls have increased for an independent inquiry into breast care at Ennis .
The UHG review report of Ms Moriarty's case, seen by irishhealth.com, states that twice during the summer of 2007, Ms Moriarty had abnormalities reported in x-rays and other tests.
The report says the contacts she had at Ennis hospital during the summer of 2007 "show a number of interactions in which the communication of test results and time taken for appropriate action fell short of highest standards."
It notes there was a seven-week delay in acting on the objective evidence of a problem, initially identified in a chest x-ray on July 3, until a CT was requested in late August. There was a further two-month delay in an appointment for a CT scan in Limerick being offered.
The report states that there has been significant focus on the chest x-rays in the internal reviews carried out by the HSE.
However, the UHG review says there are broader issues around Ms Moriarty's follow-up in St James's, her GP relationship, the repeated referral to an emergency department and not to a specialist breast centre, all of which need to be addressed.
Ms Moriarty had already been successfully treated for cancer in 2005. The UHG report states that from April 2007 there were symptoms and signs that suggested metastatic breast cancer should be included in the differential diagnosis of Ms Moriarty (ie, that it should not be ruled out).
It says she attended the emergency department at Ennis on three occasions over five months, when A&Es are not an appropriate referral route for referral of patients with ongoing symptoms, and in particular when they are not resourced to investigate or manage cancer.
The report says the symptoms and signs that Ms Moriarty's cancer may have returned were apparent to her, to two GP, the A&E doctors, the medical team, the surgical team and the nurses involved in her care.
"Despite this , it took several months to make the diagnosis," the review states.
It states the flow of information about the patient's history from where she was previously treated, St James's, to her GP and from her GP to the hospital was incomplete.
The review stresses that Ennis was not a designated cancer centre under the national cancer control programme and did not have the specialist staff or proper radiology equipment to provide the necessary level of specialist care.
It says at several levels there were systemic failures to expedite matters and make the diagnosis.
The key failure in this process was the inability to recognise that Ann Moriarty, as someone with a breast cancer diagnosis, should have been referred to a specialist unit in the first instance.
The report also mentions administrative failures at Ennis hospital that need to be addressed.
It states however,that unfortunately, early diagnosis of breast cancer when it recurs does not change the eventual outcome in terms of survival, and the goals of treatment are to relieve symptoms and palliate.
Meanwhile, it has emerged that the Dean of the Faculty Of Radiology Prof Peter McCarthy, told the HSE at the end of June that an investigation into the circumstances of the Ann Moriarty case was warranted.
Prof McCarthy, in a letter to Ann Doherty of the HSE National Hospital's Office on June 30, said, referring to their conversation regarding Ms Moriarty's case: "it appears clear from what you have told me that an investigation into the circumstances of this particular case is warranted."
However, he also pointed out that that human factors need to be taken into account, and the fact that a radiologist misses an abnormality on an x-ray does not mean that he or she is incompetent.
Prof McCarthy also refers to research which states that the expected error rate of chest x-rays for cancer in the lung may be up to 20%. It was eventually confirmed that Ms Moriarty's cancer had spread.
Prof McCarthy said unless there is a specific allegation of systematic clinical incompetence, the Faculty would feel that a large-scale review of the radiologist's work is not warranted.
Prof Mc Carthy has already stated publicly that the misreading of Ms Moriarty's x-ray by a locum consultant radiologist was felt to be an isolated incident.
In the second misdiagnosis case involving Ennis revealed yesterday, the woman concerned, Ms Edel Kelly, was erroneously given the all clear after an ultrasound and a core biopsy . However, proposed further 'clinical correlation' of the results was not acted on.
nk Posted:
23/09/2008 11:29 |
| Today I am more afraid than ever that wherever a woman presents herself with possible breast cancer problems, things will not go as they should. All this talk of centres of excellence is all very well but to be excellent prove it to me.... |
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