ANALYSIS: A report into medical mistakes follows warnings about the shortage of radiologists, writes Eithne Donnellan
YESTERDAY WOULD have been considered a good day to bury bad news given the huge focus on the US presidential election.
The Health Service Executive seized the moment to publish the shocking findings of a review of the work of one locum consultant radiologist who was employed at two hospitals in the northeast for a year spanning 2006 and 2007.
The findings are heart-wrenching.
Nine patients whose lung cancer was not picked up on by the elderly doctor on initial chest X-rays missed out on many opportunities.
Eight of them are dead and at least one of these, a mother, missed out on a major chance of her cancer being cured.
Others missed out on the chance to spend more time with their loved ones and on opportunities for greater pain control as their lives came to an end.
Their families missed out, too, and their grief was added to when they learned about the mistakes made.
"All the families were clearly deeply troubled by the detailed analysis contained in the reports on the impact that the . . . missed diagnoses had on their family member," the report says.
"They had understandable reactions of frustration and sometimes anger at what they saw as a failure of the system to deliver safe care."
The report doesn't say precisely why the errors were made. It just identifies them.
And while it does stress that errors are a fact of life in radiology - it says international studies put the error rate in general radiology practice at between 2 and 20 per cent - the reviewers were so concerned they have said the locum in this case should be referred to the Medical Council here and its equivalent in the UK, where the doctor also worked.
The doctor at the centre of the review is in his 70s and lives in Scotland.
He never worked at any Irish hospitals other than in Drogheda and Navan and the report says the appropriate checks, including references, were taken up before he was employed.
There is a hint in relation to what went wrong, and why, in the consultant's own comments on the review findings.
He pointed to "hindsight bias" but also to his overall workload, his work environment and in particular to the radiological case-mix that he was assigned.
The review itself doesn't refer to staffing levels in radiology in the northeast and whether they are appropriate to the growing workload there.
It simply says the Louth/Meath hospitals' radiology department has had no more than one or two locum consultant radiologists employed at any one time over recent years out of a complement of 10 consultant radiologists.
But it emerged last May that a senior radiologist warned management of the Louth/Meath Hospital Group in November 2001 that the number of full-time radiologists in Drogheda was "wholly inadequate" for the workload and that "mistakes will be made".
It seems the warning may have gone unheeded.
Furthermore, warnings about the need for audit and peer review of consultants' work were included in the Lourdes Hospital Inquiry report, published in 2006.
A lack of audit allowed the former obstetrician Dr Michael Neary to remove women's wombs unnecessarily for many years. Lack of audit of this locum radiologist's work has also led to awful repercussions for patients.
When the HSE announced the review of the locum's work in May, some eight months after concerns were first raised, it hired an outside firm to dispatch letters to about 4,900 patients whose X-rays were being reviewed.
Some went to the wrong addresses and yesterday's report indicates 179 also went to patients who had died, causing "understandable distress to their relatives".
Now families of the nine patients who were misdiagnosed are insisting lessons be learned.
Only time will tell whether any lessons are learned in this time of widescale cutbacks.