11 patients had cancer diagnoses delayed and four have since died: Kerry hospital review finds
A total of eleven people had their cancer diagnoses delayed and four have since died, according to “a look-back review” of more than 46,000 scans, belonging to more than 26,000 patients at University Hospital Kerry.
The single biggest such review of images and scans ever conducted in the State got underway last year after serious concerns came to light in July/August 2017 about three patients whose conditions were either missed or misread.
The look back was into the work of a single radiologist who no longer works at the hospital.
The consultant radiologist had been responsible for 46,234 images including CT Scans, Ultrasound Scans and Chest X-Rays examination between March 2016 and July 2017.
Among the main recommendations by the outside radiologist who carried out the reivew is the need for the HSE and the Faculty of Radiologists to define acceptable volumes of work for individual radiologists.
There is also a recommendation to examine how quality improvement programme guidelines can be modified for smaller hospitals relying on locum radiologists, and that a national integrated medical imaging system should be implemented in all acute hospitals.
Patients and families were being briefed this lunchtime ahead of a press conference scheduled to get underway this afternoon.
In its executive summary the report finds: "The main finding of the look-back review was that there was a substantial rate of unreported clinically significant findings requiring clinical review to determine if patients should be recalled for imaging.
"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, who 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 Lookback Report.
"All eleven cases are the subject of further system analysis review investigations which are being shared with individual patients and families.
"The findings of the audit provide a level of assurance 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 diagnosis when repeat imaging was undertaken. These diagnoses were not present or visible, even in retrospect, on the original examination.
The report goes on to make the following recommendations:
Hospital Level
1 The Hospital Manager, UHK 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. This process should be integrated with clinical governance within the hospital and the quality improvement programme in radiology.
2 The Hospital Manager, UHK to support the appointed Clinical Lead for Radiology with contracted sessional commitment to quality monitoring and improvement of services; peer review; and performance monitoring for professional staff.
3 The Hospital Manager, UHK to oversee the development of monthly business reports for the radiology department with defined and agreed metrics. Hospital Management should consider inclusion of the following: individual workload patterns and outputs by modality; staffing data; waiting lists; turnaround times; machine utilisation; peer comparison activity; incidents and complaints reporting; and development of department specific Policies, Procedures, Protocols and Guidelines.
Group Level
1 The CEO S/SWHG to commission an external review of the management of the radiology department in University Hospital Kerry. This review should focus on the working of the department, including the working relationships between the staff. The aim of the review would be to identify and make recommendations on any deficiencies that may exist so that the work environment is improved and recruitment efforts for permanent staff are more likely to succeed.
2 The CEO S/SWHG to appoint a Group Clinical Lead for Radiology with a defined job description to develop peer review audits across the hospital group at departmental and individual Consultant Radiologist level against the Faculty of Radiologists Quality Improvement Guidelines. Smaller radiology departments within the group need to work as part of a bigger group structure for reviewing the quality of reporting.
3 Hospital Managers within S/SWHG will ensure that each radiology department will continue to be held accountable for local audits reported through the hospital’s clinical governance structure, including the hospital’s quality & safety committee.
4. The Group Clinical Lead for Radiology will define the governance process to identify, escalate and manage any deterioration in a departments’ performance and the group’s external peer review process.
5. The overall requirement to provide assurance on the quality and recruitment of locum Doctors in medical practice will continue. This process requires ongoing review and monitoring by the hospital and hospital group.
National Level
6. The HSE and Faculty of Radiologists should work to define acceptable volumes of work for individual radiologists. We note that this work consists of ‘countable’ reporting activity and other ‘non-countable’ activities in interventional radiology administration and other duties (Brady, 2011).
The HSE should ensure that all radiology departments have appropriate reporting capacity to deal with the volume of imaging produced. Where the reporting capacity is insufficient, this can be dealt with via external or locum support but should be dealt with in the long term by full-time appointments within the HSE.
The hospital group structure may provide a mechanism whereby reporting capacity in one HSE hospital may be shared with another via NIMIS.
7. The Faculty of Radiologists should examine how future versions of the Quality Improvement Programme guidelines can be modified to support smaller hospitals with a reliance on locum radiologists.
8. The National Integrated Medical Imaging System (NIMIS) should be implemented in all acute hospitals. Having NIMIS in place in UHK was hugely beneficial in carrying out this extensive audit. All hospitals on the one system would support audit requirements; external peer review; and oversight.
NIMIS also provides a simple mechanism whereby the HSE can provide remote reporting to support sites where the reporting capacity is not sufficient or where there is a lack of local expertise in certain areas.
The report can be read in full here
