5th March 2008
HSE apologises to patients and lessons from this experience will ensure that similar situations are handled appropriately in the future.
The HSE today published the Clinical Review of Mammography Services at the Midland Regional Hospital, Portlaoise, for the period November 2003 to August 2007, which has been completed by Dr Ann O’Doherty. The outcome of the clinical review of Breast Ultrasound Services at the hospital was also published. Breast imaging services were stopped at the hospital in August 2007.
The HSE wishes to apologise to the nine patients whose diagnosis had been delayed as a result of shortfalls in clinical quality standards at Portlaoise Hospital.
The HSE also expresses regret for the upset that was caused to all the other patients who were the subject of the clinical review.
The HSE will be writing to these women in the next few days offering them an opportunity to express their views about the process if they wish to do so.
A dedicated HSE advice line will be available today for anybody with concerns relating to breast care services. The number for the advice line is 1800 – 252 041 and will be available from 2.00-5.30pm today as well as Thursday – Friday this week from 9.00am-5.30pm.
Dr O’Doherty’s report concludes that best practice in breast imaging services was not adhered to at Portlaoise Hospital.
This included the way images were processed, the absence of Triple Assessment and diagnostic multidisciplinary meetings.
As a result the safety, quality and standards of many aspects of the service fell well below achievable best breast imaging practice and this resulted in a significant and avoidable delay in the diagnosis of breast cancer.
Dr O’Doherty states that there is no evidence base to determine an acceptable misdiagnosis rate in highly symptomatic breast cancer services; though it is well recognised that even in the centres operating to the highest standards some women with breast cancer will have a delayed diagnosis.
She goes on to say that the false negative (misdiagnosis) rate in this review on aggregate falls within the false negative rates published within similar reviews.
In accepting the recommendations of Dr Doherty’s report, the HSE is appealing to all health care professionals involved in providing cancer service to redouble their efforts to transfer cancer services to the eight centres of excellence announced last year as quickly as possible.
National Director of the National Hospital’s Office, Ms Ann Doherty said that the HSE regretted very much the manner in which events unfolded surrounding the Review but was confident that the reasons for the shortfall in quality and safety had been identified and reported on.
“Breast imaging services were stopped at the hospital in Portlaoise and this report shows us that we have to redouble our efforts to ensure that all symptomatic breast imaging services are transferred to the eight designated Centres for cancer care as quickly as possible.”
The HSE also published today the clinical review of breast ultrasounds carried out at Portlaoise Hospital.
The period for the review was agreed in September 2007 and it was decided that an examination of every breast ultrasound in conjunction with a review of each patient’s clinical history would be carried out for patients who received treatment at the Midland Regional Hospital Portlaoise between August 2005 and August 2007.
The breast ultrasound reports and medical notes of 607 patients were reviewed. All subsequent diagnostic tests carried out were negative. The review of ultrasounds, therefore, did not reveal any case of a missed or delayed diagnosis.
National Cancer Control Programme
The National Hospitals Office will transfer full responsibility for all symptomatic breast services to the National Cancer Control Programme by the end of March 2008.
In keeping with this plan the National Cancer Control Programme has recently completed a detailed review of the resource requirements to create capacity for the progressive transfer of all symptomatic breast cancer services to the eight designated cancer centres with the objective of completing 60% transfer by the end of 2008 and 90% by the end of 2009.
The resource requirement review was based on the National Quality Assurance Standards for Symptomatic Breast Disease Services and resulted in additional funding to the eight centres from the NCCP, of €5.8 Million for the implementation of the programme.
In addition to the discontinuation of breast services at 13 hospitals announced in September 2007, the transfer of any remaining breast cancer services from the Midland Regional Hospital will be complete by the end of March 2008.
Breast services have also transferred from Clonmel to Waterford, and from James Connolly Memorial Hospital to Beaumont, and from Mullingar to the Mater Hospital.
It is anticipated that breast services from Drogheda, Tralee, Wexford, and Kilkenny will transfer over the next six months with Sligo and Castlebar transferring towards the end of the year.
Final dates for these transfers will depend on confirmation that the necessary capacity is in place in the designated centres. As already announced patients in non designated centres will continue to receive chemotherapy and supportive care locally as they do at present.
The HSE Board Review
The Department of Health and Children have today published a report on the circumstances that led to the decision by HSE in August 2007 to suspend Breast Radiology Services at Portlaoise Hospital (carried out by Ann Doherty, Director of the National Hospitals Office) and the HSE’s Board’s review of the management of all events following the decision to suspend breast radiology services at the Midland Regional Hospital, Portlaoise.
With regard to the latter report, the Board of the HSE, through a Board Committee, had appointed Mr. John Fitzgerald as the external independent person to assist and carry out this review.
Mr Fitzgerald was asked to determine the facts relating to:
- the manner in which the HSE dealt with patients throughout the period;
- the governance and management of all aspects of the process; and
- the communication arrangements with patients, internally within the HSE and with the Department of the Health and Children.
In accepting the report, at its meeting on 21st February the Board noted the finding by Mr. Fitzgerald that he did not identify any suggestion of willful neglect by any individual/s involved in the process.
However, the HSE accepts that problems arose from systemic weaknesses of governance, management and communications in dealing with the situation that arose at Midland Regional Hospital Portlaoise during the period of the review.
The HSE is determined that lessons will be learned from this experience and that similar situations are handled appropriately in the future.
To this end the HSE has is finalising a serious incident management protocol to guide the response to such adverse events. The purpose of this protocol is to clearly outline the procedures to be followed when a serious incident occurs. In particular, the protocol will include guidelines on the release of information during the response process. The protocol should apply to all HSE staff and to those providing services on behalf of the HSE.
Furthermore, a clear management and governance process will be put in place by HSE management to manage all aspects of a response to a serious incident. The process to be followed in each case will have as its absolute priority the position of the patients involved over and above any other considerations.
The process will be overseen by a member of the HSE senior management team with adequate dedicated resources to facilitate the required level of response to support both the management of the process and the clinical and administrative aspects of the response. The process will include provision for establishing terms of reference and for communications with patients during the progression of a response to the serious incident.
Last updated on: 05 / 03 / 2008