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THE MINISTER FOR Health Simon Harris has said that he’s “deeply saddened” by the impact misread radiology scans had on families in the Kerry area.
Yesterday, a review of all 46,000 radiology scans examined by a single consultant radiologist between March 2016 and July 2017 was published. It found that of the 26,754 individual patients, 11 individuals had their cancer diagnosis delayed. Of those 11 people, four have since died.
“On a human level and on a personal level, I’m extraordinarily saddened to what’s happened to the 11 families impacted, and particularly the four people who have passed away and my thoughts are with those families,” Harris told reporters today.
The Dáil was told today that a 71-year-old man, whose family claim he is among those who has had his cancer diagnosis delayed, “doesn’t have long left”.
Sinn Féin’s Pearse Doherty told the Dáil that the 71-year-old had three x-rays where his cancer wasn’t picked up, and his symptoms persisted.
Doherty said that a GP referred him for another scan, where it was discovered that he was misdiagnosed.
“[By this time], the missed lung cancer had spread and wrapped around the main artery of his heart. He went through horrific treatment, his wife has said, and he’s only a short time left.
“His family is of the belief that if his cancer was detected in any of the three x-rays, his prognosis would not be terminal.”
Numbers breakdown
Dr Gerard O’Callaghan, Chair of the Safety Incident Management Team, said that this was the “biggest radiology look-back carried out in this country”. So here’s how the numbers breakdown in the report:
The percentage of ‘Score 1′ ratings out of the total of 46,234 scans reviewed is approximately 97%. When you include Score 2 in that, it represents around 99.8%.
According to a 2013 report on the factors contributing to diagnostic errors in radiology, the real-time errors in daily radiology practice are an average of 3% – 5%.
A total of 422 patients were identified to be recalled following the Kerry consultant review. After repeat scans, 59 patients required a follow-up or investigation and 10 were sent to other hospitals for specialist care.
Of those 69 patients which required follow-up, that represents 0.26% of the total patients affected, and the 11 patients who had their cancer diagnosis delayed represents 0.04%.
Simon Harris commented on the scale of the investigation to reporters today.
“As Health Minister I want to preside over a health service that when something does goes wrong and sadly something does, that actions are taken swiftly, transparency and open disclosure takes place and lessons are learnt.”
“And I think when we talk about the Kerry situation we do need to recognise that this was a really large review.
Over 46,000 x-rays were reviewed, a very comprehensive body of work, and of that 46,000 around 422 needed further examination and of that, sadly there were 11 adverse incidents. Now that’s horrific for the 11 impacted, absolutely it is, but I do think we need to acknowledge that 46,000 were examined.
“So there are very serious lessons here for the hospital and for the hospital group and the HSE, and I’m satisfied that they’re taking it very seriously, and that they’re liaising with the families.”
That’s what we want the health service to do, when something does go wrong, acknowledge it went wrong, take every step to fix it, apologise and mean it, and make sure that lessons are learnt.
Dáil exchange
Tánaiste Simon Coveney told the Dáil today that the report had been published in the past 48 hours and that the 16 recommendations in the report were already being implemented.
Any families that still have questions and need answers, they need to get the full cooperation of the hospital involved.
He said that the review was triggered after complaints were made about the consultant.
“All the workload in relation to that one consultant, and has raised [these] concerns.”
He said that the government was trying to ensure that the response was “patient-centred”. Doherty asserted that forcing families to go through the courts system for compensation wasn’t “patient-centered”.
The Faculty of Radiologists, RCSI (Royal College of Surgeons in Ireland) released a response today.
The Dean of the Faculty of Radiologists, Dr Niall Sheehy said:
Over 2 million radiologic examinations are performed in HSE-run Irish hospitals every year. The vast majority of these are performed to a high standard and reported promptly and accurately. Unfortunately, no test is 100% accurate and errors may occur both in the technical performance and in the reporting of a radiologic examination. Examinations are reported by humans and humans make errors. Whilst individual errors are regrettable with potentially profound implications for the patient, errors do not always imply negligence or malpractice.
He said that full scale reviews, such as the one performed in Kerry, “are challenging to organise, time-consuming and can result in significant distress to both patients and staff involved”.
However, in certain circumstances it is necessary to perform them. The Faculty of Radiologists extends sincere sympathy to all of the patients and their relatives affected by this review. We also acknowledge the distress caused to University Hospital Kerry staff by this review.
The Faculty of Radiologists welcomed the recommendations of this report, and said that if they are implemented they will lead to more robust internal processes within UHK and other hospitals.
It added;
All Irish public radiology departments are under pressure as resources of staff and equipment are not adequate for the demands placed upon them. These problems are most acute in small departments such as University Hospital Kerry, where burdens such as on-call duty are spread between a small number of consultants. These departments frequently have difficulty in recruiting consultant radiologists and may be over-reliant on locum support and outsourcing.
“The Faculty calls for greater support for these smaller departments and for the HSE to examine how the Hospital Groups and the National Integrated Imaging System (NIMIS) can assist with this.”
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HSE are employing unqualified doctors, as a judge revealed,and nothing has been done about it and the board that is employing these unqualified doctors are still in office. Harris has no respect from staff as he is a weak minister,we need leaders.
@@mdmak33:
I’m afraid we’re fresh out of leaders for the foreseeable future. The last guy to fail as minister for health was promoted to Taoiseach. The prospects are pretty grim.
@Milk The Drones: The whole health system is a union infested basket case, as long as they hold so much power nothing will ever change.
@@mdmak33: haha, there’s a bit of irony in the fact that in calling Harris weak you are inadvertently quoting the former head of HSE, the leader of the board you hate.
We train doctors who leave the country because of the conditions offered in our health service. We employ people who present as doctors but apparently nobody checks to see if they are who they say they are. HSE is beyond reform
@marg fitzgerald: Should be a clause that they stay and serve in Irish hospitals for 5 years before they can move if they are educated here.
@Peter Hughes: Eh, the vast majority of them do… until the system breaks them and they simply have enough. It’s not like UK or US hospitals are taking people straight out of med school here and turning them lose on their own patients…
So what he is effectively saying is…. Some people have died but on the bright side more haven’t
We just seem to stumble from one crisis situation to the next in healthcare,there is no surprise when we read of each new turmoil, maybe we just hope that our own nearest and dearest are not part of the next announcement, so hard on all families concerned.
The sheer number of scans this one consultant was tasked with screening over the 15 month period in itself is alarming I’m i the only one who thinks that? Maybe he was under qualified and maybe he was just overwhelmed. If the latter is the case it really is a HSE failure. This is only an observation though I have no knowledge of the process
@Andy mc Laughlin: agree. I had to re-read that number a couple of times to make sure I was reading it right. 46,000 scans for one person to read in 15 months is astounding.
Deeply saddening to hear of any cancer diagnosis. However, internationally the accepted rate of human error is 3-5% in radiology scans. These findings appear to fall well within those margins.
@Sean Armstrong: unfortunately yes. Law of averages tells us that reading that about of scans you’d want to be some super human to get 46,000 100% correct. Serious failings in the system with relying on one person to get it right all the time. Terrible for those involved.
When are we going to dump that imbecile Harris and get someone in who knows what they’re doing. People are dying under his watch is there no accountability at all within this government?
@paddy fox: And do you actually thing firing him and even changing government will change anything?, the only way anything will change in this country is if folks stop voting for the same to corrupt parties…..which lets face it won’t happen anytime soon.
HSE couldn’t organize a piss up in a brewery
@George Beckett: HSE provides millions (yes millions) of clinical and social care interventions every week without incident. Organising a piss up in a brewery sounds more like your vocation in life.
@Seamus G: you obviously work for them. Frontline staff facilitate those consultations and interventions, hse admin staff is bloated and have grossly inflated (and unjustifiable) salaries (which they attempt to justify thinking they have comparable skill to frontline workers). It’s been a failure since it’s introduction, much more costly than the old heath boards. So how many directors do we have now on over a 100k? Triple the number of staff during recessionary times that has what? Even reduced overall productivity? Don’t defend the indefensible , talk to any frontline healthcare worker and they’ll quickly tell you who’s at fault for the shambles service.
@George Beckett: reckon the front line staff do their own payroll and pay creditors??
@James Gorman #FBPE: stop making straw man arguments. HSE staff are of course needed but the reality is they are overpaid. Health care professionals have a market value, you don’t pay them what they’re worth and they have a monetary value in another system abroad. HSE staff don’t, they are overpaid by any objective comparisons with other systems. Half their wages and it’s still the best offer they’re going to get. How many new staff have been added post 2008? I know HSE workers on 60k plus that work half their contracted hours. Directors on over 100k…don’t even get me started on the corruption there. Look at the pay scales, it’s ludicrous. The only way to solve it is a complete overhaul, it’s too big to be reformed.
There’s nothing untoward or unusual in these figures. 11 missed diagnoses out of 46,000 is a sign that a competent medical professional is available in Kerry. Human error is a factor in every single workplace, and although doctors and nurses are great they’re not superhuman. Articles like this misleading because they’re not exposing that anything is terribly wrong, we all have to understand that no screening service is ever 100% especially when it is one person reviewing 1000s of files.
Is anyone else not amazed that if there is a margin for error then why isn’t there a second check?
Also is there no technology (machine learning) that could at least do this double check
Someone will reply “it’s too costly”.
But sure it’s cost more in lives,reviews and investigations.
I HAD a 9cm tumor,on my colon,it did not show up on an x-ray or full cat scan,only on a colonoscopy….medicine is not an exact science,but doctors do their best I think…sorry for your loss .
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