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11 patients had their cancer diagnosis delayed and four have since died, Kerry review shows

The review looked at over 46,000 thousand individual images reported by a single consultant radiologist.

Image: Shutterstock/hxdbzxy

A REPORT ON a review of tens of thousands of radiology scans at University Hospital Kerry has found that 11 patients had their cancer diagnosis delayed and four have since died.

The review looked at over 46,000 thousand individual images (CT scans, ultrasound scans and chest x-ray examinations) reported by a single consultant radiologist relating to 26,754 individual patients.

The time period examined was between March 2016 and July 2017.

The consultant in question  no longer works at the hospital.

The review was ordered after three serious reportable events were identified in summer 2017 relating to three patients. 

The South/South West Hospital Group published its report on the review today.

The review found that 11 patients – including the three patients whose cases prompted the review – had their diagnoses delayed and that the delay had a serious impact on their health.  

It also identified three patients with undiagnosed cancer which had not been previously uncovered. 

Of the 11 patients, four died in the period between identifying their delay and the publication of the look-back report.

The cases are currently the subject of ongoing system analysis review investigations.

Categories

The audit of the scans was grouped into three categories in order of clinical significance. 

A total 44,831 were given a Score 1 - meaning there was agreement with original report or a minor abnormality of no ongoing clinical significance.

A further 1,298 were given a Score 2 - this related to an unreported finding that was unlikely to be of clinical significance, however, it required a review by a Clinical Subgroup. The patient may require rescanning.

Finally, 105 scans were given a Score 3. This required immediate communication to a Clinical Subgroup as the previously unreported finding was of potential or definitive significant clinical concern.

The Clinical Subgroup reviewed 1,789 radiology reports against other records to determine if the patient had appropriate follow-up care at the time of the original examination and if they required repeat scans. 

A total of 422 patients were identified to be recalled following the review. After repeat scans, 59 patients required a follow-up or investigation and 10 were sent to other hospitals for specialist care. 

“I would like to thank the patients and their families for the courtesy and understanding shown by them to the hospital staff in the course of this review,” said Dr Gerard O’Callaghan, chair of the Group Safety Incident Management Team (SIMT) that was set up. 

This cannot have been easy particularly when having to deal with devastating news which would have had a profound effect on them and their families.

 Recommendations 

A number of recommendations were issued in the report relating to UHK, SSWHG as well as healthcare at the national level. 

These included:

  • UHK hospital manager to oversee a review and enhancement of the incident reporting process in the hospital to ensure an appropriate capture of occasions where there is a disparity between the clinical diagnosis and the subsequent radiological report.
  • The CEO SSWHG to commission an external review of the management of the radiology department in UHK
  • HSE and Faculty of Radiologists to define acceptable volumes of work for individual radiologists

“The distress and worry caused to the wider community by a review of this nature is regrettable, however, where patient safety concerns exist, the HSE and the health services have a responsibility to act; to learn from the perspectives of patients and staff, and to make improvements to the delivery of radiology services,” Dr O’Callaghan said.

I would expect that the learning from this review will contribute to the improvement of radiology services, not just in UHK, but across all of our hospitals.

 Any patients who have concerns following the publication of the report can contact a helpline on 1800 742 900. The helpline will 9am to 9pm today and 9am to 5pm from Thursday onwards 

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About the author:

Cormac Fitzgerald

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