The HIQA calls for the recommendations of the Lynott Report of 2002 to be implemented when health authorities are employing locums, writes Theresa Judge
SERIOUS MEDICAL errors that resulted in failures to diagnose cancers could have been avoided if the recommendations of a 2002 report had been implemented, it has emerged.
A report published last week by the Health Information and Quality Authority (HIQA) into the care of a Co Tipperary woman whose breast cancer diagnosis was delayed by 18 months because of mistakes by two pathologists at a laboratory in University Hospital Galway (UHG) highlighted the need for tighter controls in the recruitment of locum or temporary consultants, particularly those coming from abroad. The inquiry found that a total of 13 patients had delayed diagnoses because of errors made by one pathologist.
The HIQA report called for the recommendations of the Lynott Report of 2002 to be "implemented by the HSE and other service providers and compliance should be audited regularly". It also stressed the need for multidisciplinary teams using a triple assessment (surgery, radiology, pathology) approach for cancer patients - such a system would identify "discordant findings", as in this case.
The Lynott Report was commissioned after it emerged that a British consultant psychiatrist, Dr John Harding-Price, was employed by the South Eastern Health Board in 2000 while he was suspended by the medical council in Britain. The report was prepared by Maureen Lynott, now an adviser to HSE chief executive Brendan Drumm.
Most of the eight recommendations of the Lynott Report concern steps that should be taken when health authorities employ locums from abroad.
"There is no point in having recommendations in reports if they are not implemented," said Dr James Reilly, Fine Gael health spokesman.
"Because of this dereliction of duty - and that is what this is - patients are being put at risk."
It emerged last year that the Finnish consultant at the centre of the inquiry into the care of the Tipperary woman had been sanctioned by the Finnish equivalent of the Irish Medical Council in 2004 and in 2006 over the misdiagnosis of two women with breast cancer.
He worked as a temporary consultant pathologist in Galway from September 2006 to March 2007 and moved on to work at Cork University Hospital in July and August 2007 before problems with his work became known.
Following the publication of the HIQA report last Tuesday, the HSE admitted that the work of a third consultant pathologist who worked in the laboratory of University Hospital Galway is now being reviewed. This pathologist worked in the hospital in 2004 and the HSE said that it was informed in December that this doctor had been suspended from the medical register in the UK for 18 months after concerns were raised about errors he made there.
If recruitment procedures recommended by the Lynott Report had been implemented, problems with the Finnish pathologist, Dr Antoine Geagea, would have been detected.
Among the steps recommended in the 2002 report were "interviews in all circumstances, verbal as well as written employer references, more detailed reference forms, contact with any foreign register regarding a doctor's status and written declaration from any applicant that he is not the subject of any investigation by a medical council or police in another jurisdiction."
The 2002 report further said that the medical council should "advise the employer to confirm the doctor's status in other jurisdictions directly with the foreign register" and also that a foreign doctor's registration with the medical council should be deactivated after a certain period and require reactivation and clearance from foreign registration authorities if he or she returns to work in Ireland.
It is clear that if these steps were followed in relation to Dr Geagea, the fact that he had been sanctioned by the Finnish authorities would have emerged.
Following the publication of the HIQA report, Minister for Health Mary Harney said: "The system's over-reliance on locums, and the procedures used in recruiting them, is now being addressed by the HSE. The HSE is implementing a series of measures to strengthen its procedures for recruitment in this regard."
Dr Reilly described Ms Harney's reassurances as "all talk and spin, and no action". He said a lack of management in the HSE was resulting in "a paralysis in relation to the appointment of new consultants that leads to an over-reliance on locums".
He said a system that relied on locums coming and going rather than a team of permanent staff would not be able to minimise human error. The doctor at the centre of the inquiry was found to have an error rate six times accepted norms.
Dr Reilly said that while Ms Harney maintained that more safeguards were being put in place "nobody can see it on the ground - we haven't heard of any new consultant appointments".
He said patient safety was also being compromised because HIQA's remit did not cover private hospitals - the report does not cover the Tipperary woman's care in Barrington's Hospital in Limerick - and because HIQA had "no teeth to enforce its findings on private hospitals, it cannot impose penalties or sanctions".
Donal Duffy of the Irish Hospital Consultants Association said difficulties arose particularly when locum cover was needed at short notice, as in the case of illness cover. He said that to do checks with foreign registration bodies could take more time than was available in such cases.
The commitment the Government has given to employ more consultants should reduce the reliance on locums, he said. "The question now is are those appointments going to be made given the current climate - they may not come as quickly as we would have liked."
Duffy said that while some parts of the HSE "are quite good at arranging locum cover well in advance, some have been tardy". Current restrictions on recruitment were also adding to the problem, he claimed.
"There are difficulties now in getting approval for locum cover and this can cause delays which impedes proper checks being made," he said.
The HIQA report states: "As in many countries, the current recruitment process for permanent, temporary or locum consultants does not include objective assessment of technical ability but relies on the subjective opinion of referees. Clear procedures for the recruitment of temporary or locum staff, including comprehensible guidance on the use of recruitment agencies and guidance on references should be developed and applied across the broader HSE.
"Such procedures are particularly important given the reliance on locum staff within the health services."
In addition to recommending that the Lynott Report be implemented, HIQA also included in its 12 recommendations "a formal policy for the recruitment of locum and temporary consultant staff should be established and implemented nationally to ensure more robust and effective arrangements and quality assurance mechanisms".
The steps taken by UHG in appointing Dr C are outlined in the report and it is clear that a recruitment agency played a central role. Written references were provided. The report states: "A verbal recommendation had been received by the pathology department in respect of Dr C by another temporary consultant pathologist working at that time in UHG pathology department."
He was registered with the Irish Medical Council in September 2006, again with the help of the agency. The report does not address the issue of whether the Irish Medical Council knew that he had been sanctioned in Finland.
The HIQA report also states: "The investigation team concluded that a specific procedure for the recruitment of temporary and locum consultant staff should be developed, particularly in relation to the take-up, validation and consideration of references, as well as the arrangement for working with specialist recruitment agencies.
"Since the investigation, the HSE has issued interim guidance on the recruitment of locum medical consultants," the report states.
The report states that the new consultant contract "should provide the basis for more explicit accountability of consultants through practice plans and a reporting relationship with clinical directors".
Both University Hospital Galway and Cork University Hospital said this week that new national guidelines issued by the HSE in March 2008 for the hiring of locum/temporary consultants were now being applied.
The 51-year-old Tipperary woman, when her breast cancer was eventually diagnosed 18 months after she had first presented, had to undergo a mastectomy, radiotherapy and chemotherapy. She has called for the report's recommendations to be "implemented in full, for the safety and wellbeing of all". If the report was "left to gather dust what has happened to me will have been in vain".
She also called for the regulation of private hospitals.