ANALYSIS:The handling of X-rays at Tallaght hospital points to a major systems failure. But how did it happen and who was responsible?
THE WARNING could not have been starker.
“I have been informed by one of your managers that ‘two years of GP referral letters’ have not been opened or reached the consultant to whom they are addressed,” reads the letter from Prof Tom O’Dowd to the chairman of Tallaght hospital’s board on April 22nd last.
“I have been further informed at a meeting that there are ‘thousands of unread X-rays’ in the radiology department. Either of these issues on their own is of the utmost gravity for patient safety . . . Quite clearly there are problems, but it is not all clear they are being addressed.”
Prof O’Dowd has never received a response.
In fact, it took almost a year for the full scale of the problem to finally tumble out into the open.
Almost 58,000 X-rays taken over a four-year period had never been reviewed by consultant radiologists. The blunder meant at least two cancer patients received a delayed diagnosis; one of them has since died and the other is still being treated.
The scandal has exposed a massive systems failure in one of the State’s leading acute hospitals. In the process, it has turned the spotlight on other hospitals and what procedures they have in place to handle X-ray results.
Most damning of all is that after assurances that issues over mammography services and the quality of cancer tests in recent years had been addressed, patients are asking whether they still place their confidence in the health service.
SO HOW did such a major systems failure occur?
The majority of the almost 58,000 scans are understood to have been orthopaedic: broken bones, fractures, dislocations. There should be a standard procedure when an X-ray is carried out. It starts with a hospital doctor or GP requesting a test. It only finishes when a specialist doctor or consultant formally examines the X-ray and records a formal result.
“The consultant is the final piece in the jigsaw,” says a hospital consultant, familiar with this process. “You have occasions where experienced junior doctors make decisions, but best practice means a consultant signs off on a test.”
Yet at Tallaght – which was considered one of the best hospitals for checking X-rays due to its advanced technology for reading X-rays – tests were being reviewed by non-radiologists. This meant thousands of X-rays were allowed to pile up, formally unreported, over a four-year period. Consultants involved in radiology say this represents a fundamental failure of the process.
The precise reason for this systems failure is likely to form part of an investigation by the Health Service Executive. Initial explanations from Tallaght point to a changeover in the systems they used to handle X-rays. They also point out that the majority of scans were handled appropriately – the 58,000 X-rays represent about 6 per cent of tests carried out over a four-year period.
WE KNOW the first red flag was raised over the backlog of X-rays as early as April 22nd last, following Prof O’Dowd’s letter. So why did so little happen until December of that year?
The Health Information Quality Authority (Hiqa) has helped cast some light over the mishandling of the situation. It was contacted on April 24th by Prof O’Dowd about the backlog. On foot of this, Hiqa met the former chief executive of Tallaght Hospital, Michael Lyons, in late June. Hiqa says it was told by Mr Lyons there was a “historic” problem and that all X-rays were being reported.
The hospital claimed there was a backlog of 4,000 X-rays which would not normally be reported by radiologists, such as dental X-rays. The backlog would be cleared by the end of July 2009.
Yet even before the summer, doctors say rumours had been swirling in medical circles of a major backlog of somewhere in the region of 20,000 unreported cases at the time.
At a further meeting in August last year between Hiqa and Mr Lyons, the authority says it received further assurances that the backlog was being reduced. Clearly, Hiqa wasn’t fully satisfied.
It requested a written report on the issue in September and followed it up with letters to the former chief executive in October and again in November, repeating this request.
THERE ARE questions to be answered by chairman of the board Lyndon MacCann and former chief executive Michael Lyons over the handling of this issue. But there are questions, too, for its current chief executive, Prof Kevin Conlon.
In a statement on Tuesday, he said he learned of the backlog on his appointment on December 14th last. Yet it is clear he attended meetings in his capacity as medical director about backlogs of X-rays with Hiqa at least as early as last August.
A spokeswoman for the hospital says he only became fully aware of the scale of the problem after ordering a full review once he was appointed chief executive in December.
The Irish Hospital Consultants Association says much of the blame may lie with the understaffing at Tallaght. Despite being the second busiest of Dublin’s teaching hospitals, it has just seven consultant radiologists. Other hospitals like Beaumont have about 15, the Mater has about 13 and James’s has 11 consultant radiologists.
“The accepted and recommended standard is that Tallaght should have 18 consultant radiologists,” says Donal Duffy, assistant secretary general of the association. “In excess of 40 letters were written to hospital management about this matter by the radiologists.”
Yesterday, the HSE said it would ask all of its hospitals to confirm whether they had similar problems to Tallaght with delays in reviewing X-rays. Until that audit was completed, it said it could not provide reassurance.
It is a sentiment all too familiar with Rebecca O’Malley. She was incorrectly given an all-clear for breast cancer following a misdiagnosis. She says this latest controversy is yet another slap in the face for patients.
“No wonder there is a lack of trust in the honesty and openness of our health service when something goes wrong,” she says. “The public can be forgiven for doubting whether any lessons have been learned at all over misdiagnoses in recent years.”