BACKGROUND:"We left the hospital so relieved to have been told that no problem had been found . . ."
THE REVELATION that yet another cancer patient in this country was not diagnosed and treated at the earliest possible opportunity is likely to cause further public concern about the state of our health services.
In the latest case Ann Moriarty, a 53-year-old wife and mother, who was in remission from breast cancer attended Ennis General Hospital on June 11th last year and a chest X-ray on her was wrongly reported as normal.
She had cause to have other visits to the hospital during last summer and at no time was the fact that she was terminally ill picked up on. Even in August 2007, junior doctors told her another chest X-ray looked fine.
And when she attended the hospital's AE unit that same month, having lost a lot of weight, she was discharged home by a junior doctor. This decision even surprised nurses.
A few days later, after a second opinion was sought at a private hospital in Galway, the awful truth was conveyed to her family. She was dying. She died in April this year.
Her devastated husband Karl Henry, who now wants an independent investigation to ensure no other patients had X-rays at Ennis misread, recalled yesterday how he and his late wife left Ennis hospital in August 2007 relieved she had again been given the all-clear.
"We left the hospital so relieved to have been told that no problem had been found and we walked back to our car like two happy kids."
Within days though it was discovered errors had been made and she wouldn't be around for much longer; around to see her then 12-year-old son grow up.
Mr Henry said yesterday: "The nightmare the family has had to endure over the past year almost defies description . . . the people who fail to read X-rays properly or fail to act on seriously abnormal blood results need to wake up and realise that people can and do die when they don't do their job properly".
One of the two unpublished internal reviews of the care given to his wife at Ennis carried out by the HSE makes several recommendations and concludes: "It is difficult to say that if the metastatic lesion had been picked up in June 2007 instead of August 2007, whether the outcome would have been different for Mrs M. It is clear however, that MWRH (Mid Western Regional Hospital) Ennis did not provide optimal care to Mrs M".
The report found "clear evidence that the radiologist who reported on the chest X-ray of 11th June 2007 failed to pick up a 3cm poorly defined opacity just above the aortic knuckle, highly suggestive of a metastatic lesion". It also refers to "lack of supervision of junior medical staff".
Ms Moriarty's family are also upset that a mammogram carried out on Ms Moriarty at St James's Hospital Dublin - one of the State's eight designated cancer centres - in April 2007, when she was also given a clean bill of health, is missing.
She had a breast removed at that hospital two years earlier and the mammogram on her second breast was reported as normal in 2007. However, the family wonder if this could possibly have been a correct report, given that she was found to be terminally ill four months later.
Not surprising this woman's family, who moved from Dublin to Ennis in 2006, still have many questions. They now want to meet the Minister for Health Mary Harney to discuss their concerns.
Over the past year there have been several inquiries into the misdiagnosis of cancer patients across the State. There was the inquiry into the case of Rebecca O'Malley, whose breast cancer diagnosis was delayed by 14 months after an error was made in the laboratory of Cork University Hospital; the inquiry into the delayed diagnosis of a 51-year-old Tipperary woman after her biopsy results were wrongly read at Galway's University College Hospital; an inquiry into care provided to breast cancer patients at Barringtons Hospital in Limerick; an inquiry into the misdiagnosis of nine breast cancer patients at Portlaoise General Hospital; and reviews of the work of locum consultant radiologists in the northeast and in Galway are ongoing.
It is true that mistakes can and will always be made in our health service, but this latest case shows yet again that all the necessary checks and balances are still not in place to ensure errors are picked up quickly. Patient safety, despite all the assurances to the contrary, still does not seem to be the main priority in our healthcare system.
MAIN POINTS
Chest X-ray taken on June 11th, 2007, was misread. It also took 22 days for that X-ray to be reported on, which is "very lengthy".
Doctors in the emergency department wrongly noted that another chest X-ray on August 11th, 2007, "looks fine".
Junior doctors decided to discharge her home on August 11th, 2007, but noted she should have a surgical follow-up appointment. This appointment was not arranged, "possibly due to a failure in communication".
An auditable process needs to be developed whereby consultants review all critical decisions made by junior medical staff, especially with regard to discharging patients from care.
Abnormal blood test results were put in her file in August 2007 without being acted on.
There were clear systems failures in the internal arrangements for follow-up appointments and for appropriate sign-off of radiology and pathology reports.
An auditable process needs to be developed to ensure that all tests requested during an episode of care have been reported on, reviewed, actioned and signed off as being done prior to patient discharge.
A system needs to be developed to address issues arising from the volume of work, the staffing arrangements in radiology, the prioritisation system for reporting and the auditing of services to optimise patient safety.
The provision of a dedicated CT scanning service at Ennis needs to be reviewed as a matter of urgency.