Surgeon in mistaken operation case guilty

A LEADING paediatric surgeon has been found guilty of three allegations of poor professional performance at a Medical Council fitness-to-practise inquiry after a 2½-year-old patient in his care had an unnecessary tongue-tie operation.

The inquiry committee also raised concerns about “systems failures, weaknesses and errors” in procedures at Our Lady’s Children’s Hospital in Crumlin.

Prof Martin Corbally, who was a paediatric surgeon at the hospital when the incident happened in 2010, incorrectly described the procedure required by Baby X in her notes, which amounted to poor professional performance, the inquiry committee found.

He also failed to communicate adequately to Dr Farhan Tareen, the registrar to whom he delegated the operation, and failed to apply appropriate standards of clinical judgment expected from a surgeon with his experience. In April 2010, Baby X from Co Meath had a tongue-tie operation, a lingual frenulectomy releasing the fold of skin beneath her tongue, when what she needed was an upper labial frenulectomy, to release the fold of skin attaching her upper lip to her gum. She subsequently had the correct operation.

In a statement issued last night by a public relations company, Prof Corbally said: “I am disappointed [at the ruling] . . . It is regrettable that trusted hospital systems failed to ensure a safe procedure but I am happy to note that Baby X has made a full and complete recovery.”

Prof Corbally had recorded the procedure in the patient’s notes as “upper lingual frenulectomy” and an administrator had entered the procedure on the hospital computer system as “tongue-tie”. The inquiry had been told “tongue-tie” was the only possible option on the computer coding system at the time for all frenulectomies. And it was from this coding system the theatre list was compiled.

The consultant had also told the inquiry if he knew Baby X was a private patient, he would not have delegated the procedure. Evidence had also been heard that Baby X’s family had raised concerns about the procedure in advance of the operation.

Prof Corbally had previously faced allegations of professional misconduct when a patient in his care had the wrong kidney removed despite pre-surgery concerns raised by the parents. That case concluded when an inquiry agreed to accept undertakings from Prof Corbally and a junior doctor to whom he had delegated the operation, about their future medical performance.

The chairman of the inquiry committee, Prof Gerry Bury, said the committee was satisfied the allegations proven against Prof Corbally amounted to poor professional performance. There was “significant evidence of systems failures, weaknesses and errors” in surgical procedures at the hospital. They had real concerns about systems issues including inadequate surgical booking and coding systems. There had been a failure to instigate the “surgical pause” policy, which is a delay before surgery to ensure everything is correct in advance of the procedure, and there had been a failure to implement the hospital’s own correct site surgical policy.

There was also a weakness in clinical leadership, the committee said. While the committee had heard the specific surgical coding problem identified in the case had been addressed, it was unclear if the hospital had carried out a comprehensive coding review of all surgical procedures. He said the committee would recommend the Medical Council investigate the issues at the hospital. He also said it would make recommendations to the council in relation to sanctions to be imposed on Prof Corbally, who is chief of staff at King Hamad University Hospital in Bahrain.