MORE THAN half the medical negligence claims settled against hospitals arising out of treatment in their emergency departments are diagnosis related, many of them brought as a result of a failure by junior doctors to identify injuries, usually fractures.
The trend was uncovered following a recent analysis of all emergency department claims closed by the State Claims Agency between mid-2002 and the end of last year.
It found that in many instances junior doctors missed fractures on X-rays because of a lack of knowledge or competence in radiology.
More than half of the 203 cases filed during the period under review did not proceed to claim and a quarter of them were settled out of court.
Of the cases settled out of court, 59 per cent were diagnosis related, with 94 per cent of them involving a failure to diagnose.
More often than not, it was a senior house officer (SHO) – a grade of junior doctor – who was being sued in these cases. SHOs were involved in 74 per cent of closed claims. Consultants were involved in just 8 per cent of them.
However, it is SHOs who evaluate and treat the majority of patients presenting to emergency departments.
“Given that in the Irish public healthcare system the majority of emergency department attendances are seen by NCHDs [non-consultant hospital doctors or junior doctors], it is important to have adequate training and supervision with regard to radiograph interpretation and follow up, with more senior colleagues encouraged,” the review states.
It also states that a standardised reporting system in hospitals is crucial, so that missed fractures identified later by a consultant radiologist when reviewing X-rays initially interpreted by junior doctors, are immediately fed back to the emergency department, so the patients involved can be followed up quickly. This hasn’t happened in all cases in the past.
The review has been published by the State Claims Agency’s Clinical Indemnity Scheme in its latest newsletter and, according to Ciarán Breen, director of the agency, the data is being fed back to junior doctors to enable them to learn from it.
Mr Breen said it showed there were issues around the lack of supervision and training of junior doctors, as well as a failure sometimes by these doctors to refer a patient to a more senior colleague if they are in doubt about a diagnosis.
He said a common injury which had been misdiagnosed was a scaphoid fracture, a type of wrist injury which usually caused pain at the base of the thumb, accompanied by swelling in the same area.
One case taken by a young man whose scaphoid fracture wasn’t picked up on initial presentation at A&E, and who ended up with permanent limitation of movement in his wrist, was settled for a six-figure sum.
“We also had one case where an A&E department doctor failed to diagnose a subarachnoid haemorrhage in a woman and we ended up paying €6.5 million in compensation because the woman was so extremely badly affected by what happened . . .
“Her symptoms ought to have indicated that this was a problem that she had and, of course, had it been got when she originally presented herself to A&E then her outcome would have been significantly better,” Mr Breen said.
Emergency medicine is responsible for 15 per cent of all medical negligence claims. Given that the State Claims Agency paid out a total of €73.9 million in respect of clinical claims between 2003 and 2008, the cost of emergency department claims during this period would appear to amount to about €11 million.
The recent McCarthy report, by UCD economist Colm McCarthy on how savings might be made in the public sector, included a recommendation that hospitals should contribute to the cost of medical negligence claims, to improve incentives for risk management.
Mr Breen agrees with this proposal.