Missed opportunities in spotting Wexford cancer misdiagnoses, report finds
Financial pressures on BowelScreen programme led to lack of regular audits
Pat Fitzpatrick was given the all-clear following a colonoscopy in Wexford General Hospital in 2013. He was diagnosed with bowel cancer in 2015 and died last April. Photo: Dee Fitzpatrick
Concerns were repeatedly raised by a member of staff about possible cancer misdiagnoses at Wexford General Hospital but no action was taken for over a year, according to a report on the incident.
The Irish Cancer Society said the report raised serious questions about how incidents are reported, why staff concerns were not acted upon and how long the doctor at the centre of the controversy would have continued to perform colonoscopies but for the intervention of surgeons in other hospitals.
The family of one of patients who died after his cancer was missed despite being tested in the BowelScreen programme also criticised the failure of health managers to act on the concerns of a member of staff. Dee Fitzpatrick, whose father Pat (73) died last April, two years after being diagnosed with bowel cancer, said the outcome might have been different if the work of the unit had been audited.
The report by Scottish surgeon Prof Robert Steele criticised the failure of services to detect the substandard work of a consultant that led to the problem.
There were “missed opportunities” by local and national governance structures to prevent, detect and address substandard performance by the doctor who carried out hundreds of colonoscopies, he found.
The 24-age report, published by the HSE, is also critical of a lack of regular performance audits by the BowelScreen programme at the time of the incident, which it linked to “significant financial pressures” on the health service at the time, as well as a “steep learning curve” in the programme.
The report says BowelScreen learned a great deal from the investigation of the Wexford errors and its quality assurance process is now “greatly enhanced”, with colonoscopy data collected on a regular basis.
The ICS expressed confidence in the BowelScreen service, but called for immediate action from Minister for Health Simon Harris to implement the report’s recommendations, beginning with a the establishment of a formal process for expressing concerns.
Donal Buggy, ICS head of services, said the report raised more questions than it answered.”What is clear is that a staff member at Wexford General Hospital raised concerns about the performance of Clinician Y on five separate occasions over the course of nine months. It took a further year before a recall of patients under Clinician Y was approved.”
“It is evident that mechanisms for raising concerns need to be strengthened, so that staff who have legitimate clinical concerns are listened to, and their concerns are followed up in a timely manner with appropriate action. Had the concerns of the HSE employee been addressed early in this case, it is likely that the poor performance could have been identified and acted on promptly, improving outcomes for those undergoing colonoscopy procedures.”
BowelScreen is offered to all men and women between the ages of 60 and 69, with the plan being to extend this to 55-74 in the long term.
The Wexford incident arose after a patient who had received a screening colonoscopy in April 2013 was diagnosed with cancer a year later. A second case then emerged; a member of staff, identified only as “Clinician Y”, performed both colonoscopies.
A review or “look-back” process involving 615 people who had received colonoscopies in Wexford was undertaken. Of these, 384 had received the test under Clinician Y. Of this group, 13 cancers were detected in people who had had a colonoscopy that was reported to be normal.
Prof Steele, professor of surgery at the University of Dundee and clinical director of the Scottish Bowel Screening Programme, found the look-back process was carried out in a timely and efficient manner, and to the highest possible standards. There were “missed early opportunities” to identify shortcomings in the work of Clinician Y, but there were significant “mitigating circumstances” surrounding this.
These included the fact that the doctor had a good reputation as a reliable endoscopist, and that there was clear evidence of frequent communication between the clinical lead at the hospital and BowelScreen.
Had the concerns expressed by a member of staff in Wexford about Clinician Y’s performance been acted upon promptly, the effect of the incident could have been ameliorated, the report states.
The HSE said that although it had carried out its own review, it had been it appropriate and necessary “given the gravity and scale of the incident” to commission an external report.
BowelScreen, in response to Prof Steele’s findings, has implemented a new policy to manage safety incidents in a standardised and appropriate manner, according to the HSE. Early warning systems have been strengthened and measures taken to ensure a proactive response is taken where staff raise concerns.
Ms Fitzpatrick criticised the failure of health managers to act on the concerns expressed by a member of staff about the doctor as the centre of the incident.
“This is an exceptionally difficult day for our family as we learn further details of how my Dad and 12 other families were failed by the BowelScreen process,” his daughter said, responding to the publication of an external review into the incident.
Ms Fitzpatrick said her father had a colonoscopy in Wexford in February 2013, following symptoms of bowel cancer. One month later, a HSE employee in the hospital expressed concern about the consultant performing the colonoscopy.
“That staff member went on to express these concerns again in May 2013 to BowelScreen by telephone and was reassured that the concerns would be communicated to the clinical lead at Wexford. A conversation took place between the clinical lead at BowelScreen and the clinical lead of Wexford.
“This very brave worker highlighted issues with this consultant on five occasion, to both WGH and BowelScreen itself. They asked for an audit of the photos to be undertaken. That didn’t happen.”
“If a full audit of the colonoscopies had occurred at that time, the outcome for my Dad and our family would be very different.”
Ms Fitzpatrick said it was difficult to understand why the evidence from the concerned workers not included in the HSE’s Safety Incident Management Team’s report last year. It also raises the question of how “open” the “Open Disclosures” policy is. We attended two meetings with WGH and they never disclosed this information to us.”