The Health Information and Quality Authority today published the Report of its investigation into the provision of services to Ms A by the Health Service Executive (HSE) at University Hospital Galway (UHG) in relation to her symptomatic breast disease, and the provision of Pathology and Symptomatic Breast Disease Services by the Executive at the Hospital. 

The Board of the Authority, having given very careful consideration, approved the Report of the Investigation Team at a Board Meeting on the 9th July and authorised the publication of the Report.

Ms A was a patient at Barrington’s Hospital, a private hospital in Limerick, but, as was the practice at the time, her pathology samples were sent to the pathology department in UHG for analysis. The Authority’s investigation focused on the services provided to Ms A by UHG, given that it is authorised to conduct investigations into HSE funded hospitals only. A separate investigation was conducted by the Department of Health and Children and Barrington’s Hospital into Ms A’s care in that hospital (published April 2008).

In relation to Ms A’s care, the main findings of the Report are as follows:

• Two different pathologists working in UHG misdiagnosed Ms A’s breast cancer - Dr B in September 2005 and Dr C, a locum pathologist, in March 2007;
• As a result of the misdiagnosis which occurred, Ms A’s treatment for breast cancer was delayed;
• There was no arrangement in place for pathologists from UHG to participate in multidisciplinary review of cases at Barrington’s Hospital and as a result, an important opportunity to correct for these interpretative errors was lost;
• Although UHG was paid for the service, the agreement between the two hospitals was based on an informal arrangement between clinicians, and no formal governance arrangements were in place to oversee the service.

To ascertain whether there was a need for wider concern about the work of Dr B and Dr C, and to ensure as far as possible that no other patient had received a misdiagnosis, the Investigation Team reviewed the caseload of the two pathologists.

This entailed reviewing 200 breast histology patient cases reported on by Dr B and 747 breast and non-breast cytology patient cases and 123 gynaecological cytology cases reported on by Dr C.

This review found that in the case of Dr B, a single interpretive error, the misdiagnosis of Patient A, occurred and there was no cause for wider concern about their work.

The review of Dr C’s work identified 49 patients where the reviewers differed from Dr C in their findings. The discrepancies found in these 49 patients had the potential to affect the clinical management and care for those patients and therefore all patients were followed up by UHG and, where necessary recalled for consultation, further investigation or treatment. Of the 123 gynaecological cytology cases reviewed by the Investigation Team, 35 women whose specimens were reported on by Dr C were contacted for precautionary follow-up as a result of a difference of opinion between the review and Dr C’s reporting.

Although carried out according to guidance in place at the time, some aspects of Dr C’s appointment also raise questions for UHG and the wider HSE. A number of specific recommendations in the Report deal with this issue.

As in many countries, the current recruitment process for permanent, temporary or locum consultants does not include objective assessment of technical ability but relies on the subjective opinion of referees. Clear procedures for the recruitment of temporary or locum staff, including comprehensible guidance on the use of recruitment agencies and guidance on references should be developed and applied across the broader HSE. Such procedures are particularly important given the reliance on locum staff within the health services.

Commenting on the Report, Jon Billings, Director of Healthcare Quality, in the Health Information and Quality Authority, said: “The fact that Ms A experienced two interpretive errors, separated by 18 months, by two different consultant pathologists serves to emphasise the importance of having fully functioning triple assessment and Multidisciplinary Team Meetings (MDTs) in place, irrespective of where the patient is cared for. Failure by the clinicians and institutions concerned to have such arrangements in place was a significant factor in her delayed diagnosis.”

“Overall, the Investigation Team found that the Symptomatic Breast Disease Services at UHG were well run – although it makes recommendations for improvements in the Pathology Department’s quality assurance systems. The Hospital was responsive once the interpretive errors came to light. Lessons learned by UHG in responding to this incident should be examined by corporate HSE to inform the approach adopted nationally,” said Jon Billings.

Jon Billings paid tribute to the courage of Ms A in allowing her story to be told.

“Ms A has shown great courage at a time of great personal difficulty, in sharing her experiences with the Investigation Team. Her hope, and that of the Investigation Team, is that the findings and recommendations of this Report are implemented by all those organisations who have a responsibility for symptomatic breast disease services, both public and private, for the future benefit of others using the services.”

The Report makes 12 recommendations which it believes must be implemented by the HSE in order to safeguard the delivery of a quality service to patients. The Report states that the corporate HSE executive management team should nominate a specific Director accountable for ensuring the development of an implementation plan for these recommendations. This, it recommends, should include a clear timeframe with milestones. Progress against the plan should be made public and reported to the Board of the HSE.

Ends.

Further Information: 

Marty Whelan, Head of Communications and Stakeholder Engagement

01 8047651 / 086 2447623 mwhelan@hiqa.ie