Wrong procedure a result of 'human error'


A CONSULTANT paediatrician who incorrectly recorded a procedure to be carried out on a 2½-year-old girl – who was later given the wrong operation – told a Medical Council fitness-to-practise committee yesterday the mistake was “human error”.

Prof Martin Corbally, who was a paediatric surgeon at Our Lady’s Children’s Hospital in Crumlin when the incident happened in 2010, said he was “probably quite tired” when he filled out the letter in question and accepted he made a mistake. But he said he had correctly recorded the procedure on the admissions card as “tongue tie upper frenulum” and administration had not completed the hospital booking system correctly because they omitted the words “upper frenulum”. “That is where the error really lay,” he said.

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.

The after-effects of the mistake included constant drooling, her mother had said, and her tongue hung out of her mouth. But she subsequently made a full recovery.

The girl was under the care of Prof Corbally, now chief of staff at King Hamad University Hospital in Bahrain. He had delegated the operation to a registrar. The consultant is facing four allegations of poor professional performance including that he incorrectly described the procedure needed by her on her notes and delegated the procedure to a junior without communicating adequately.

He had previously faced allegations of professional misconduct when a patient in his care had the wrong kidney removed. 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.

Giving evidence yesterday via video link, Prof Corbally said he could not be expected to remember the names of his patients.

“I would see 80 to 100 patients a week between my three clinics and I was not really remembering their names,” he said. He also said he had “no way of knowing” the procedure that should have been carried out on Baby X when she attended for surgery weeks after he had seen her in outpatients.

If the procedure had been transcribed properly by administration he would have remembered, he said. He also said on the morning of the surgery he had been very busy and had three patients in intensive care.

He denied his instruction to his junior “to release the tongue tie” amounted to poor professional performance. There had been a series of errors in the case, he said.

“To err is human,” he said. “Everybody can make a mistake.” Prof Corbally said after the incident, procedures at the hospital had been improved. He also said he was “deeply concerned” about risk in surgery and had taken a course in risk management after the case involving the patient who had the wrong kidney removed. He had also carried out a study about parental involvement in medical staff meetings ahead of surgery on children.

In earlier evidence, an expert witness for the Medical Council, UK consultant paediatric surgeon Hugh Grant, from John Radcliffe Hospital, Oxford, said he believed the transcript error made by Prof Corbally amounted to poor professional performance and “started the chain of events” that led to the incident.

Under cross-examination from Eileen Barrington SC, for Prof Corbally, who queried whether a transcript error could be poor professional performance, Mr Grant said if you call a lump on the arm a lump on the leg you are applying your knowledge incorrectly which amounted to poor professional performance.

The case continues today.