The Tallaght Hospital unreported x-ray and unprocessed referral letter scandal review has slammed deficiencies in management and governance systems at the hospital.
More than 26,000 of nearly 58,000 x-rays which went unreported on by radiologists over many years at Dublin's Tallaght Hospital should have been reported on by these specialists, under recent HSE x-ray reporting guidelines, the probe has found.
The report is highly critical of the governance and management of Tallaght and outlines how deficiencies in these areas were a major factor in the difficulties with unreported x-rays and nearly 3,500 unprocessed GP referral letters.
The report notes with both these issues there was a lack of guidelines, no performance measurement or monitoring, and efforts to solve problems did not succeed. The report cited problems with how the hospital board governed Tallaght, and identifies a shortage of radiologists as a key factor in the problems that arose.
Other issues raised include poor communication between management and doctors at Tallaght and the absences of the then hospital CEO, Michael Lyons, on sick leave for lengthy periiods.
However, the report says the resulting constant rotation of senior personnel in acting roles cannot fully explain the consistent failure of management to take effective action to deal with problems as they arose.
(View the full Hayes report here)
The review was established after the backlog story was broken by RTE News in March of this year, three months after the HSE had learned from Tallaght of the full extent of the unreported x-rays.
Responding to the report, Health Minister Mary Harney noted that the review had clearly identified serious concerns about the robustness of the hospital's management and governance structure and said she intended to meet with the hospital and the HSE to establish how the report's recommendations for improvements can be implemented as soon as possible.
Chairman of the independent review group, former Northern Ireland Ombudsman Dr Maurice Hayes, cited consultant radiologists' heavy workload, lack of written protocols and guidelines on reporting x-rays, difficulties with IT systems, difficulties with secretarial and support services and the inability of a number of hospital initiatives to effect improvements as among the reasons behind the x-ray backlog scandal.
However, despite the report identifying a shortage of radiolgists as a key factor in the scandal, the HSE has yet to fill two badly-needed new radiologist posts approved back in February.
The report says while there were not 30,000 "unopened" GP referral letters as previously claimed, there were nearly 3,500 referral letters where there were clear failings and delays in how these patients were processed, There was no evidence that a serious event occurred as a result of these delays, although patients had to suffer the worry of delayed treatment.
A total of 157 remaining patients whose appointments were delayed as a result of the referral letter issue are scheduled to have their appointments with consultants before the end of the month, the HSE said.
As with the x-ray backlog problem, the report said the letters issue did not arise from a single cause or from the action or inaction of a single individual. There had been multiple factors and failures to act by many people who collectively brought about the problem, it said.
There were, the review found, weaknesses in the systems and processes that Tallaght applied to the handling of referral letters for outpatient appointments. There were weaknesses in planning of specialist services which meant too many referrals for too few outpatient appointment slots.
The report found there was a particular problem with organising orthopaedic care due to pressures in this specialty.
There was also weak engagement and communication with GPs.
Two patients had a delayed diagnosis as a result of delays in x-ray reporting and one has since died. These cases were not within the backlog looked at in the Hayes review, but are the subject of a separate report sent to the families concerned.
However, no adverse events relating to the 57,921 x-rays in the backlog were found in the Hayes review. The review said that while all these x-rays were read, they were not properly reported on.
It says even had recently drawn-up HSE guidelines on which x-rays should be reported on by radiologists when there is a staff shortage had been implemented, 26,275 of the x-rays in the backlog were not, but should have been, reported on by radiologists.
The review report found that the backlog of unreported x-rays was caused by the hospital having too few radiologists against a background of a workload growing in volume and complexity, problems with IT and systems and secretarial services, and deficiencies in governance and administration at Tallaght.
The report found that despite a number of initiatives to deal with the backlog issue being taken by the hospital at various times, it was not properly addressed. The report says the x-ray backlog was ongoing from 2005 to 2009, but a significant backlog was reported as far back as 2003.
The Hayes Review says no durable solution to the ongoing problem was found despite the x-ray reporting problems being frequently raised by radiologists and other consultants at the hospital.
A cancer specialist back in 2006 raised concerns about a 17-day delay in reporting an x-ray on a major lung condition, and said such delays were becoming commonplace.
The report says radiologists frequently told senior management at the hospital that all-x-rays should be reported.
However, the report notes that there was no formal agreed written policy on prioritisation of reporting of x-rays.
The report also shows the huge discrepancies in internal hospital estimations of the x-ray backlog at Tallaght between 2003 and 2009, ranging from 5,000 back in 2003, and rising to 50,000 in September 2008 until the final figure of 58,000 was confirmed at the end of last year.
However, no specific explanation is offered in the report as to why hospital management told the State health safety body HIQA in June of last year that the backlog was only 4,000.
A figure of 50,000 had been stated in an internal hospital report the previous September, while another figure of 35,100 was stated in an internal communication in December 2008, and yet another estimate of 42,000 was made the following April.
In January 2009, another internal report estimated that the unreported x-ray backlog could be as many as much as 70,000. The report notes there was was considerable confusion existing at the hospital over the precise x-ray backlog numbers.
Dr Hayes told reporters the hospital's assessment of the backlog at the time had been "floating." When the true nature of the backlog emerged in December 2009, it was cleared by April 2010.
He told reporters that there was no evidence of a "cover-up" of the extent of the real x-ray backlog, but said the problem with arriving at the correct figure had been due to confusion within the system.
The report says there could be confusion over what constituted a single x-ray or multiple x-rays from the point of view of reporting.
Asked if there had been any evidence that disciplinary action was required against specific Tallaght staff members or groups of staff over what happened, Dr Hayes said this "was not a very clear-cut issue".
He said while failures in the system had been found, there had been no malevolence involved.
The Hayes report contains a number of recommendations to improve practice at Tallaght and other hospitals, including proposals for improved management and governance at the south Dublin hospital.
The HSE acknowledged today that the Hayes report identified significant failings in how the x-ray and letter backlog developed and noted that Tallaght had since completed considerable work on these issues.
It said all unreported films have now been appopriately reported on and 97% of patients affected by the unprocessed letters have been seen by a consultant. The hospital, it said was also addressing management and governance issues.
The HSE says it has approved funding for two additional radiologists at Tallaght and together with tighter x-ray reporting guidelines now in place, it was "satisfied the that the backlog of unreported films will not occur."
The Minister for Health noted that the report had referred to problems with the management structure, culture and style at Tallaght, as well as a number of administrative deficits.
Fine Gael health spokesman Dr James Reilly noted that the two urgently-needed radiologists had yet to be appointed at Tallaght despite all the concerns expressed.
He also noted there were 30 occasions when consultants raised radiology issues between 2005 and 2009 at Tallaght.
Dr Reilly said the public now needed to know that the highest standards of clinical and management procedures were now in place at Tallaght.
See also:'No cover up found'
13,500 on OPD lists at Tallaght
'Tallaght - a culture of neglect'
Scandalous. Clearly the HSE has become too big to be effective.