5th December 2018
First and foremost, the South/South West Hospital Group, University Hospital Kerry and the Health Service Executive (HSE) would like to apologise sincerely and unreservedly to all patients and families who have been affected by this review.
The South / South West Hospital Group (SSWHG) today published findings from its comprehensive Radiology look-back review of all radiology images reported by a single Consultant Radiologist at University Hospital Kerry (UHK) in the period March 2016 to July 2017. This review was prompted by the notification to hospital management of three serious reportable events, each associated with a diagnostic error, in July and August 2017.
For patient safety concerns, an urgent risk assessment was conducted by Consultant Radiologists at UHK to assess the impact of the diagnostic errors. Following this assessment, a formal review was initiated and the matter was escalated to the SSWHG who recommended that a look-back review would be carried out. This was approved by the National Director of the Acute Hospital Division, HSE, on the 30th of August, 2017 and a Group Safety Incident Management Team (SIMT) was established, which was chaired by the Group’s Chief Operations Officer. The first meeting of the SIMT took place on the 12th of September, 2017.
The look-back review was carried out in accordance with the HSE Guidance for the Implementation of a Look-back Review Process (HSE 2015). A look-back review comprises of a three-phased approach: risk assessment; an audit of records to identify those potentially affected, and patient recall. As part of the UHK look-back audit, a review of 46,234 images (CT Scans, Ultrasound Scans and Chest X-Rays examinations) reported by an individual Consultant Radiologist relating to 26,754 individual patients between March 2016 and July 2017 was undertaken.
The purpose of the extensive review was to identify and address patient safety issues and to ensure patients were informed and had access to follow-up care if necessary.
The peer review audit was grouped into three categories, Score 1, Score 2, and Score 3.
- 44,831 were given a Score 1. This indicated there was agreement with original report or a minor abnormality of no on-going 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 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.
In total, the Clinical Subgroup reviewed 1,789 radiology reports against other clinical records to determine if the patient had appropriate follow-up care at the time of the original examination and if the patient required repeat imaging. 422 patients were identified for recall following the audit and clinical review. Following repeat imaging 59 patients required further clinical follow-up and / or investigations and 10 patients were referred to other hospitals for specialist care.
Eleven patients had their diagnosis delayed which had a serious impact on their health, including the initial three cases which prompted the review. The look-back found three patients with undiagnosed cancer, which had not previously been identified. Regrettably four of the eleven patients have passed away in the intervening time period between identifying their delay and the publication of the look-back Report.
All these cases are the subject of further on-going system analysis review investigations, which are being shared with individual patients and their families.
Dr Gerard O’Callaghan, Chair of the SIMT stated:
“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. 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.”
Results of the UHK Look-back Review:
The look-back review found that there was a substantial rate of unreported clinically significant findings requiring clinical review to determine if patients should be recalled for imaging. The review was designed to identify patients who may need on-going and additional care and was not an individual professional review.
A key finding of the audit noted that whilst patients were exposed to risk, the majority of patients did not suffer any direct harm due to the diligence of their treating Doctors.
A number of patients were discovered to have unrelated diagnoses where the diagnosis was made on repeat imaging and was not found to be present or visible, even in retrospect on the original radiological examination reported. The participation of these patients therefore in the recall process has been responsible for detecting these diagnoses. These patients are now in appropriate care or surveillance pathways.
Dr Gerard O’Callaghan, Chair of the SIMT, stated:
“This was the biggest radiology look-back carried out in this country. It was carried out very professionally in a very short time period by dedicated hospital staff at UHK who went over and above their normal duties to complete the process as judiciously as possible whilst at the same time keeping the patients at the centre of all efforts and decisions. I would also like to express my thanks to the external radiology and medical staff as well as staff in the SSWHG for their support during this process.”
Summary of Recommendations:
Hospital level Recommendations
- 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.
- UHK Hospital Manager to support the appointed Clinical Lead for Radiology with a contracted sessional commitment to quality monitoring and improvement of services; peer review, and performance monitoring for professional staff.
- UHK Hospital Manager to oversee the development of monthly business reports for the radiology department with defined and agreed metrics.
- The CEO SSWHG to commission an external review of the management of the radiology department in UHK
- CEO SSWHG to appoint a Group Clinical Lead for Radiology
- Hospital managers within SSWHG will ensure that each radiology department will continue to be held accountable for local audits reported though the hospital’s clinical governance structure, including the hospital’s quality and safety committee
- Group Clinical Lead for Radiology will define governance process
- Overall requirement to provide assurance on the quality and recruitment of locum doctors in medical practice will continue
National level recommendations
- HSE and Faculty of Radiologists to define acceptable volumes of work for individual radiologists
- Faculty of Radiologists to examine how Quality Improvement Programme guidelines can be modified to support smaller hospitals with a reliance on locum radiologists
- National Integrated Medical Imaging System (NIMIS) should be implemented in all acute hospitals
Dr Gerard O’Callaghan, Chair of the SIMT, stated:
“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. 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”
Patients of UHK who have any concerns following the publication of the look-back review report are invited to contact the helpline - 1800 742 900. This will operate between 9am to 9pm on Wednesday and 9am – 5pm from Thursday onwards. The helpline captures patient contact details, which is passed onto the appropriate clinicians for further contact.
Issued on behalf of the South / South West Hospital Group by Heneghan PR
Nigel Heneghan / Eoghan Ó Neachtain / Emma Gallagher
Tel: 0862587206 / 0876288030 / 0879249349
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Last updated on: 05 / 12 / 2018