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'His family believes that if his cancer was detected in any of the 3 x-rays, his prognosis wouldn't be terminal'

Thousands of scans affecting 26,000 patients were reviewed – of those, 11 people’s cancer diagnoses were delayed, it was found.

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:

  • 44,831 were given a Score 1. There was agreement with the original report or a minor abnormality of no ongoing clinical significance.
  • 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.
  • 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 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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24 Comments
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    Mute David Wool
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    Apr 17th 2020, 11:58 AM

    So sad. RIP

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    Mute Logan Shepherd
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    Apr 17th 2020, 12:02 PM

    RIP and I’m truly sorry that you had to make the ultimate sacrifice to care for others.

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    Mute Never Reply
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    Apr 17th 2020, 12:03 PM

    May they rest in peace. Where would we be without these brave people.
    Thank you to everyone in our health care services.

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    Mute Joe Bergin. stay home, stay safe.
    Favourite Joe Bergin. stay home, stay safe.
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    Apr 17th 2020, 12:27 PM

    I knew Jim. I remember him since around the time he started school. An honest, decent man always. RIP Jim and condolences to all those affected.

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    Mute Barry Buckley
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    Apr 17th 2020, 11:59 AM

    Rip.

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    Mute Marie McG
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    Apr 17th 2020, 12:20 PM

    Heartbreaking. RIP to these kind gentle souls.
    I know the vast majority are staying home but there are others still not sticking to the rules. My neighbour is still visiting her sister and friends – inconsiderate.

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    Mute filthypete
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    Apr 17th 2020, 1:41 PM

    @Marie McG: and just as bad Marie, they’re accepting her as a visitor. Those selfish people should reflect on those two selfless people who passed away.

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    Mute Marie McG
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    Apr 18th 2020, 3:10 AM

    @filthypete: I agree. Sadly some people don’t think the rules apply to them. Anyone reporting others for flouting these rules?

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    Mute Eoin Kernan
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    Apr 17th 2020, 1:11 PM

    Dying and grieving in isolation is one of the cruelest aspects of life right now.

    For those who have lost someone close recently, I’m offering a simple gesture to create a video memoir which can be shared privately among family and friends. No charge. All the details can be found here: https://twitter.com/eoinkernan/status/1247901328069689346?s=21

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    Mute Logan Shepherd
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    Apr 17th 2020, 1:15 PM

    @Eoin Kernan: Nice one Eoin.

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    Mute Elaynehb
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    Apr 17th 2020, 2:48 PM

    @Eoin Kernan: that’s very kind of you and I’d say very appreciated by those who avail of it

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    Mute Shane Cormican
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    Apr 17th 2020, 3:39 PM

    @Eoin Kernan: this is one of the most effective posts I have seen in this ever!! Well done Eoin most generous of you

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    Mute Eoin Kernan
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    Apr 17th 2020, 8:55 PM

    @Eoin Kernan: thank you all for your kind words. The kindest thing you could do is to share this with your network so it reaches those who may need it.

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    Mute Brian Dunne
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    Apr 17th 2020, 12:10 PM

    Very sad. They died helping others

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    Mute Fran O'Keeffe
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    Apr 17th 2020, 12:10 PM

    R. I. P I HOPE THE HSE WILL LOOK AFTER THERE Family’s financially its the least they could do very sad.

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    Mute Fr. Fintan Stack
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    Apr 17th 2020, 2:13 PM

    As a nation every year we celebrate the Easter rising and the people who gave their lives for their country. Going forward people like Catherine and Jim should also be remembered annually as people who gave their lives for their country……. Not just locally but as a country. Its the least we can do. R.I.P.

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    Mute Brian Lawlor
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    Apr 17th 2020, 12:43 PM

    Heroes…

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    Mute Joe Vlogs
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    Apr 17th 2020, 12:23 PM

    @Nathan: I noticed tin foil had run out of supermarkets. I’m pretty sure hundreds of thousands are dying and economies are being decimated as part of a concerted global effort by governments to have you under surveillance.

    As mentioned by the above posters, sincere condolences to all the health workers and patients who have passed away. The ultimate selfless sacrifice for the good of greater society. Imagine risking your life everyday for people you don’t know, but rely on you for help. True, true heroes.

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    Mute Feargal O Connor
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    Apr 17th 2020, 1:52 PM

    It brings it much closer to home being a health care worker.
    R.I.P

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    Mute rendams
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    Apr 17th 2020, 2:24 PM

    Hospital front liners now really deserve some sort of a hazard pay or a once off tax breaks from the government to value them even more

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    Mute Larry Roe
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    Apr 17th 2020, 1:08 PM

    So so sad

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    Mute Sportmad
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    Apr 17th 2020, 2:48 PM

    Sad news and for all those that have passed may they rest in peace.
    Essential workers need to be remembered for this and what they do..
    Stay safe

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    Mute Hossam Ibrahim
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    Apr 17th 2020, 4:07 PM

    RIP heroes!

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    Mute JJ Ryan
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    Apr 17th 2020, 10:12 PM

    RIP. Condolences to both families. My sister works in the same hospital. #Stayhomestaysafe

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    Mute kieran
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    Apr 18th 2020, 3:00 AM

    God bless them….loved and remembered.

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    Mute John Connolly
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    Apr 17th 2020, 5:35 PM

    Certin people have very little respect for front line health workers an even think they can bring a judicial review of measures designed to protect everyone.

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    Mute Bonzo
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    Apr 17th 2020, 6:04 PM

    It’s very sad hopefully we see better results soon , stay home and stay safe family over everything ! RIP

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    Mute Ian Brennan
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    Apr 17th 2020, 1:18 PM

    Rest in peace Jim u wer some character

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    Mute Ian Brennan
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    Apr 17th 2020, 1:19 PM

    Rest in peace Jim you wer some character

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