Review finds ‘errors and delays’ in cancer diagnoses at Letterkenny Hospital

Women wrongly triaged and not booked for follow-up appointments, says report

There were 133 women diagnosed with endometrial cancer at Letterkenny University Hospital between 2010 and last year, with 38 patients waiting longer than 100 days from initial referral to diagnosis.  File photograph: Trevor McBride

There were 133 women diagnosed with endometrial cancer at Letterkenny University Hospital between 2010 and last year, with 38 patients waiting longer than 100 days from initial referral to diagnosis. File photograph: Trevor McBride

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Women who suffered delayed cancer diagnosis at Letterkenny University Hospital were wrongly triaged and not booked in for follow-up appointments in some cases, a damning review of its gynaecological services has found.

The review, carried out by hospital group Saolta, was ordered by the Health Service Executive (HSE) last autumn after a number of cases of alleged missed cancers at the unit were revealed.

Whistleblower and Donegal-born doctor Margaret MacMahon, whose late sister Carol’s endometrial cancer was missed for two years, says up to 20 more women suffered missed or delayed diagnosis, some of whom have since died.

Ordered as a result of her allegations, the review looked at just six cases over a nine-year period where women suffered a suspected missed or delayed diagnosis of endometrial cancer.

“With specific reference to the cases which triggered this review, the common theme was delay in diagnosis,” the report found.

“There were several causes for this including poor follow-up practices, and poor triage and administrative practices; all compounded by ineffective communication.

“In essence, it was a failure to individualise and provide a person-centred approach to the care of these patients.”

The report said it is “clear” in all cases that the women received “unsatisfactory” care and that the gynaecology triage system is “cumbersome, inefficient and represents a significant opportunity for error and delay”.

Dr MacMahon, a consultant physician based in Bristol, said the report exposes quality and safety failings at Letterkenny but “glosses over” the human cost of those shortcomings.

“What really matters here is people died,” she told The Irish Times.

“The report hasn’t given the outcome of these failures, the harm or injury caused by this diabolical service. It hasn’t given the general public the real information, which is what were the effects of these failings on human lives, including death.”

Dr MacMahon said: “Letterkenny is a symptom of a cancer within the Irish gynaecology service. Ireland has a recurring theme with failings for women’s health services which is set to continue unless that cancer is managed.”

Dr MacMahon said that “until there is accountability for these tragedies there will be many more to come”.

Disclosed

It is a matter of public interest, she said, that information is disclosed on the number of lives affected and how they were affected by the failings at Letterkenny.

Delays were noted in several key stages including from urgent GP referrals to a gynaecology appointment, from gynaecology appointment to urgent diagnostics – such as ultrasound or hysteroscopy – and from diagnostics to intervention.

Carol McMahon, who died in March 2015, suffered from endometrial cancer. Her sister, Donegal-born doctor Margaret McMahon, says up to 20 more women suffered missed or delayed diagnosis, some of whom have since died
Carol McMahon, who died in March 2015, suffered from endometrial cancer. Her sister, Donegal-born doctor Margaret McMahon, says up to 20 more women suffered missed or delayed diagnosis, some of whom have since died

“In some cases, there is evidence of incorrect triaging, evidence of not being correctly placed on the patient management system and evidence of not being booked in for follow-up outpatient appointments, diagnostics and/or interventions,” the report states.

Failure to communicate effectively with patients is “a common theme which underlined a number of incidents”.

In one such case, staff could not contact over the telephone a vulnerable patient who did not attend appointments as well as a planned procedure. But the hospital did not contact the woman’s GP – as it should do under national guidelines – which led to a delayed diagnosis.

“While the source of the error rested with the triage and administrative processes, this error was compounded by the missed opportunity to follow up a patient who was in the care of [the hospital] with symptoms that indicated endometrial cancer and clear indications for urgent diagnostics.”

In a number of cases, patients went to the hospital for related and unrelated procedures, and “it is clear that in these cases the opportunity to follow up and ensure that the patient was booked into their respective diagnostic/interventional appointment before discharge was missed”.

There were 133 women diagnosed with endometrial cancer at Letterkenny University Hospital between 2010 and last year, with 38 patients waiting longer than 100 days from initial referral to diagnosis.

The gynaecological service is beset with “large and worsening” waiting lists and “there is evidence that insufficient effort is being made to improve the situation”, the report found.

No-show rate of 29 per cent

It notes that 55 women are on a waiting list for an “urgent” gynaecological appointment at the hospital – two of them waiting between three and four years, seven waiting between two and three years, and two more waiting between 18 months and two years – have yet to be seen.

There is also a “very urgent” waiting list at the hospital – a category not recognised by national protocols – but it is not monitored for the length of time it takes for patients to be seen, it was found.

“The gynaecology service overbook their clinics with ‘urgent’ or ‘very urgent’ referrals, and rely on other patients not attending to manage the overflow,” the report states.

A high rate of patients not turning up for appointments at the service – up to 29 per cent – has the effect of demoralising staff, and making recruitment and retention of high-quality staff “very difficult”, it adds.

Shortcomings in nursing gynaecology staff training are also highlighted.

Furthermore, it was found the unit does not appear to have a “meaningful relationship” with other gynaecological services in the same hospital group Saolta, which “may account for the isolated impression” it gives.

While a post-menopausal bleeding clinic was set up at the hospital two years ago in response to one of the cases, it has been found to be “inefficient”, with “unsatisfactory waiting times” and “insufficient capacity”.

Tony Canavan, CEO of Saolta, said management and medics are “working very hard to improve the service provided at the hospital”.

“The delays in accessing the gynaecology service experienced by some women with post-menopausal bleeding in Letterkenny University Hospital in the past are unacceptable and, on behalf of both the Saolta group and the hospital, I want to apologise to any woman or family impacted in any way by these delays.”

Saolta said it has already started work on implementing recommendations in the review.

Seán Murphy, manager at Letterkenny University Hospital, also apologised to women “where the care provided to them fell short of the standards that they should expect”.

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