Dáil debates
Thursday, 15 May 2008
Private Notice Questions
Re-examination of X-rays and CAT scans.
4:00 pm
Brendan Howlin (Wexford, Labour)
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I will call on the Deputies who tabled questions to the Minister for Health and Children in the order in which they submitted their questions to my office.
Fergus O'Dowd (Louth, Fine Gael)
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Question : To ask the Minister for Health and Children the position regarding the 5,000 patients in the north east who will have their X-rays and CAT scans reviewed as a result of concerns regarding the work of a radiologist employed by the Health Service Executive; and why the extent of this review was denied in February 2008 by the HSE thus raising serious doubts about its credibility and integrity.
Seymour Crawford (Cavan-Monaghan, Fine Gael)
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Question : To ask the Minister for Health and Children the position regarding the 5,000 patients in the north east who will have their X-rays and CAT scans reviewed as a result of concerns about the work of a radiologist employed by the Health Service Executive; and why the extent of this review was denied in February 2008 by the HSE thus raising serious doubts about its credibility and integrity.
Joanna Tuffy (Dublin Mid West, Labour)
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Question : To ask the Minister for Health and Children the position in regard to the proposed re-examination of X-rays and CAT scans of patients in the north east; the number of patients involved; the steps being taken to advise the patients in question; when the process will be completed; when she and the HSE first became aware of the problem; and if she will make a statement on the matter.
Mary Harney (Dublin Mid West, Progressive Democrats)
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Yesterday evening, the HSE issued letters to almost 4,600 patients in the north east advising them that chest X-rays and CAT scans from 2006 and 2007 were to be reviewed. Individual patients will be notified of their result as soon as their X-ray-CAT scan has been reviewed, namely, they will be informed whether they are clear or are to be referred for further assessment.
The HSE has emphasised in its letters to patients and others that the review is for precautionary reasons. The review arises from concerns raised relating to the practice of a locum radiologist. In late 2007, it came to the attention of the HSE that a small number of patients in Our Lady of Lourdes Hospital Drogheda and Our Lady's Hospital Navan during 2006 and 2007 had their diagnosis delayed due to an abnormality on their chest X-ray not being noted on initial examination by the radiologist. These patients, through follow-up X-rays, were subsequently diagnosed with lung cancer and have all passed away.
The HSE has established a review by external experts into these four cases. The review led by Professor Muiris Fitzgerald, respiratory consultant, will allow the HSE to establish if there was a clinical significance to the delayed diagnoses. The HSE has made contact with the families concerned and remains in regular contact with them to update them on progress and to offer any appropriate supports.
I was informed in March of this year that the HSE, following further examination of the issue, was considering a separate look-back review in regard to the work of the radiologist. The HSE issued a press release on 31 March following media reports concerning radiology services in the north east. That press release was based on the information available at the time. In its subsequent assessment of the situation, and taking into account the advice of external experts, the HSE agreed the look-back review would include a small number of CAT scans.
The HSE decided that a look back exercise was required to review approximately 6,000 chest X-rays and approximately 70 CAT scans reported by the locum consultant radiologist in Drogheda and Navan from August 2006 to August 2007 to ascertain if other significant clinical findings had been missed. These X-rays-CAT scans relate to approximately 4,590 patients.
Chest radiographs are performed for many reasons. Most are done for respiratory tract infections, bronchitis, asthma, pneumonia, accidents, injuries, chest pain and heart failure. A small number would have been done for possible lung tumours, but the majority of patients who are being checked are extremely low risk and included as a measure of prudence.
The planning for this review commenced in March. A steering group was formed by the HSE on 9 April to oversee the radiology review. Between April and 14 May the steering group undertook preparatory work which included defining the methodology for the look-back exercise, sourcing radiologists to undertake the look-back, arranging indemnity for participants and working to provide assurance that any and all claims arising from this review would be covered, developing the process and resources for the look-back exercise across two X-ray departments in Navan and Drogheda, establishing the communication needs around the review and putting plans in place to meet these.
This review will be undertaken by an internal and external mixed panel of radiologists from Louth, Meath and Northern Ireland. The HSE issued letters to patients, general practitioners and public representatives by post informing them of the arrangements for the review and giving details of the HSE information line. It is expected that the review will take approximately eight weeks. In patients' interests and in keeping with the lessons learned from previous reviews, neither the HSE nor the Department will report further on specific details of the reviews until they have concluded.
Fergus O'Dowd (Louth, Fine Gael)
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That is appalling. It is absolute incompetence on the part of the Minister and the HSE and negligence in terms of their duty of care to public patients. More than seven years ago, when the old health board was going out of existence, it prepared and sent to the Department a report, the recommendations of which the Minister's predecessor, Deputy Micheál Martin accepted. This consultant plan for the north east formally reported on serious deficits in the region and a core part of the plan was a proper full time radiology service with the appointment of full-time consultants and the filling of key positions. That never happened during the Minister's time in the Department of Health and Children.
How can the Minister restore confidence in the system throughout the country? How can she ensure that locum consultants are fully and properly qualified and have all of the knowledge they require? Following what happened at Barringtons Hospital and in the midlands, does the Minister believe she is in a shameful position having to call back 6,000 X-rays of 4,600 people? It is an appalling vista and creates appalling concerns and upset for the people involved. I acknowledge and I hope, as the Minister does, that few people will be affected. However, the Minister would not need to do this unless she was advised that serious issues must be determined by this further review.
Mary Harney (Dublin Mid West, Progressive Democrats)
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A number of issues are raised. I reject the inference that this has to do with resources. Reviews of radiology and other reviews are commonplace in hospitals throughout the world. For many years in Ireland we did not review anything. We did not bring things to light, as Deputy O'Dowd knows from what happened in a maternity hospital. For 25 years the rate of caesarean hysterectomies was 300 times higher than in hospitals in Dublin and that went without investigation.
In today's era things are brought to light. In this case, a cardiologist dealing with patients recognised a possible misdiagnosis and brought it to the attention of the authorities. A dispute arose among the health care professionals as to whether we would undertake a review of all the doctor's X-rays or a limited number. The jury is out on this. Some suggest carrying out a sample review and other suggest reviews all x-rays. This is international practice because advice was sought from HIQA and outside Ireland. The view taken by the HSE, which I support, is to examine all the work carried out by the person for one year.
Reviews take place not only of locums but also of full-time consultants. Issues are raised with regard to locums, which we are addressing in the health care system. We will always depend on locums because filling consultant appointments takes time. If somebody moves from one position to another we must replace him or her quickly. In these cases, locums are always used. This person was in place for approximately 12 months. It is common practice in every health care system of which I am aware to provide services by locum consultants. I do not believe or accept the Deputy's political charge that this has something to do with resources.
The HSE has written to tell the patients the review will be carried out. In other countries and systems a review is done and patients are contacted if an issue arises. We will carry out a review of data. We will not call in patients for another X-ray unless it is necessary and something comes to light. We are being totally open and transparent and informing all of the patients as the review begins. We believe that is best practice and we are doing it in accordance with the protocol put in place after the Portlaoise inquiry.
Seymour Crawford (Cavan-Monaghan, Fine Gael)
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I thank the Minister for coming to the House to answer this issue. The fact that 4,600 patients or more are involved is enough for this to be a major source of anxiety in the area. The Minister referred to the Neary affair in Drogheda and the length of time it took to deal with the situation. Nearer home, there was the death of Ms McCabe and her child in childbirth as a result of staffing problems. There is no doubt there is a difficulty with staffing issues. It may be a different sector but it is the same problem.
Some years ago I lost a 62 year old cousin as a result of failure to diagnose through X-ray. It was not until the woman went to Northern Ireland that the situation was disclosed. She was told if she had been diagnosed six weeks earlier she would have had a chance of surviving. I am conscious of the anxiety of these patients. We need to get to the bottom of these issues and ensure that the best personnel are in place. Is the Minister satisfied that we are getting these personnel in the north east? Recently, I noticed the HSE advertised for consultants. The number of those coming to the north east, if any, is limited. We deserve as good a service as anywhere else. Will the Minister ensure that where possible fully qualified people deal with the situation and we are not depending on locums?
Mary Harney (Dublin Mid West, Progressive Democrats)
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It is important to state that there is a level of error in reading X-rays. If memory serves me right, this is in the region of 4% to 5% worldwide. The system is not perfect. The focus on health reform is to minimise the capacity for making errors by having a number of clinicians working together, having the most modern imagery and so on.
What happened in this case was that four patients with cancer had their initial diagnoses delayed. They were suffering from lung cancer, which we know is very serious. We could have decided to concentrate on those four patients — a review of those four patients is being led by Professor Muiris Fitzgerald — to establish whether the delay contributed in any way to their death or inappropriate treatment. As a precaution, it was decided that all the work of the particular radiologist should be reviewed and I believe this is appropriate.
In the past, people had to litigate to get answers. I stated previously in the House that Margaret Murphy, whose son Kevin died at the age of 19 in a hospital in this country, from adverse events that should not have happened, could not get answers and had to litigate. When she succeeded in getting compensation she gave it to a charity. That era is over. Many people advised that we did not need to conduct this type of look-back, that a sample look-back would be enough or that we should not inform the patients involved but after doing the look-back only contact those patients about whom an issue arises. There is some merit in that because patients who receive the letter will be concerned. I accept that and I wish it did not have to happen. We need to be straight and open with patients. We have assured patients in the documentation, of which I think Deputies have a copy, that this is a precautionary measure. We do not anticipate any problems. If a problem arises, treatment will be forthcoming immediately.
Joanna Tuffy (Dublin Mid West, Labour)
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I seek clarification on a number of issues following the Minister's reply. She stated she was informed about this by the HSE in March. When did the problem first come to the attention of the executive? On what date was it aware of this before the Minister was notified? She stated the review into the 4,600 patients would take eight weeks. On what date does she expect the review of the first four cases that came to light to be completed?
Mary Harney (Dublin Mid West, Progressive Democrats)
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As I understand it, a cardiologist noticed when he looked back at the diagnosis of one patient that the lung cancer diagnosis had not been made and he got in touch with HIQA about these issues. The HSE was informed in late 2007 and I became aware of this in March when I received a telephone call while I was overseas for St. Patrick's Day. The discussions between key medical experts centred on whether there should be a review, the extent of the review, its methodology and recruiting people to conduct the review. It has not been easy to get people to conduct the review and we have had to rely on radiologists from Northern Ireland to assist in it because we want it completed in a timely fashion.
With regard to the initial four cases, I do not know how long it will take Professor Fitzgerald to conclude his review but the families of the patients have been spoken to on a number of occasions and they have been met by the HSE. They are being kept in the picture where the review is concerned and, as soon as it is completed, they will be first to have a copy of it before it is even forwarded to myself or the HSE.
Fergus O'Dowd (Louth, Fine Gael)
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Seven years ago the Department was advised there was a need for permanent appointments in the radiology department but the Minister did not make them. She quite rightly referred to the Neary report and the Harding-Clarke inquiry. One of the recommendations in the report was the appointment of a lead clinician in the region to oversee the work of various specialists. Was a lead clinician appointed in the north east with responsibility for the work of all those under him or her?
The person involved in these cases was a temporary consultant. The Minister stated finance was not an issue in this regard but that is not the case. Our Lady of Lourdes Hospital was €7 million over budget in September 2007 while Louth County Hospital was €1.7 million over budget. The information I received under a freedom of information application highlights the trouble and the pressure on staff because of increased costs for oncology, medical and surgical supplies and under-funding here, there and everywhere. In January 2007, Navan hospital employed five agency NCHDs in its accident and emergency department, one agency person for surgical registration and one consultant anaesthetist and one agency medical SHO to cover sick leave. That is a large number of temporary appointments, which is unacceptable.
The Minister received a letter from Finbar Lennon, a senior consultant in Our Lady of Lourdes Hospital, in August 2007, in which he stated he was deeply concerned that the situation was very unsafe in the north east and he called for a fundamental reappraisal of the current strategy being pursued by management. Is it not a fact the Minister has failed absolutely, totally and abjectly in her duty of care to patient safety? When will the patient safety commission, which she established some time ago, report?
Mary Harney (Dublin Mid West, Progressive Democrats)
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I totally reject the political charges the Deputy has made.
Fergus O'Dowd (Louth, Fine Gael)
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They are factual, not political.
Mary Harney (Dublin Mid West, Progressive Democrats)
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The fact a hospital goes over budget does not mean it is under-funded.
Mary Harney (Dublin Mid West, Progressive Democrats)
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We cannot provide in five different institutions for the population of the north east the expertise required and that is what the reform agenda is about. First, facilities in Cavan and Louth will be strengthened.
Mary Harney (Dublin Mid West, Progressive Democrats)
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Half of all surgical patients and one third of medical patients in the Deputy's region attend Dublin hospitals. That is what they decide.
Fergus O'Dowd (Louth, Fine Gael)
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The Minister does not look after people in the north east. She should answer the questions.
Mary Harney (Dublin Mid West, Progressive Democrats)
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The reason for that is the fragmentation of services.
Mary Harney (Dublin Mid West, Progressive Democrats)
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One cannot provide in five hospitals serving a population of less than 400,000 the range of expertise the Deputy thinks should be provided everywhere.
Mary Harney (Dublin Mid West, Progressive Democrats)
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The reform agenda in the north east is being overseen by a cardiac surgeon, Dr. Eilis McGovern. Resources are being invested in the region, including consultant staff. I recently had a good meeting with the medical board representing the hospitals in the north east and most of the clinicians on the ground are buying into the reform agenda and we must maintain the momentum behind that.
This issue has nothing to with staffing.
Fergus O'Dowd (Louth, Fine Gael)
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It has everything to with it. This man was in his 70s.
Brendan Howlin (Wexford, Labour)
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The Minister, without interruption.
Mary Harney (Dublin Mid West, Progressive Democrats)
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The Portlaoise review was a permanent appointment. Is the Deputy implying errors are made by temporary staff and not by permanent staff?
Fergus O'Dowd (Louth, Fine Gael)
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Yes, absolutely. It is a fact.
Mary Harney (Dublin Mid West, Progressive Democrats)
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That is not a fact and I do not accept that. The case in Portlaoise was a permanent appointment.
Fergus O'Dowd (Louth, Fine Gael)
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This was a temporary appointment.
Mary Harney (Dublin Mid West, Progressive Democrats)
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We receive letters almost every day from people in the health service telling us everything is unsafe and we do not have enough nurses and so on. According to the OECD report, Ireland has the highest ratio of nurses in its health care system compared with any system in the world and, for example, twice as many as in France. I will not accept a failure to invest in resources leads to the issue we are discussing.
Mary Harney (Dublin Mid West, Progressive Democrats)
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Patient safety is paramount. The commission is due to report in June and, on foot of its recommendations, presumably I will come forward with legislative proposals.
Seymour Crawford (Cavan-Monaghan, Fine Gael)
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It becomes more frightening every day when the Minister denies the availability of finance does not matter. Before the North Eastern Health Board was wound down, it pointed out that because of the population increase in the region, €40 million would need to be provided so that funding would match what was available in the rest of the country. Has the temporary post been replaced by a permanent post? What steps has the Minister taken to deal with this? Will she listen to the clinicians on the ground about how serious is the situation? I have spoken to many of them in recent weeks and they did not say the Minister's proposals were safe or anywhere near it. They said the situation is extremely dangerous. Mr. Finbar Lennon was the expert adviser to the health board and he has raised more questions than anybody else about what is happening in the north east and the damage that is being done. The Minister promised that no services would be removed until services as good or better were provided but she is removing services on a daily basis and, as Deputy O'Dowd said, putting patients at risk.
Mary Harney (Dublin Mid West, Progressive Democrats)
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If trauma cases are taken to the accident and emergency departments of hospitals that cannot deal with them appropriately because they do not have the expertise, the potential for recovery by the patient is diminished by up to 25%, according to international evidence. If one is in a hospital that does not have the appropriate expertise for a condition——
Seymour Crawford (Cavan-Monaghan, Fine Gael)
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Because it has been removed.
Mary Harney (Dublin Mid West, Progressive Democrats)
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One does not need to be a genius. The OECD supports our restructuring plan for the north east.
Brendan Howlin (Wexford, Labour)
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The Minister without interruption.
Mary Harney (Dublin Mid West, Progressive Democrats)
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One cannot have the range of expertise in each of five hospitals in a region with such a small population base. The transformation plan in the north east is being overseen in the first instance by Professor Drumm, who is a clinician, and by many other clinicians, including Eilis McGovern, who is a well respected cardiac surgeon in Dublin and who has an international reputation. There is huge clinical involvement in the reform programme around the country, particularly in the north east. I am not saying for one moment, nor would I, that it has unanimity as far as the clinicians are concerned. Of course, it does not and I would not expect unanimity. However, I am satisfied that in respect of the engagement the HSE is undertaking with the College of Radiologists and other experts in the field, both here, Northern Ireland and elsewhere, we are acting appropriately as far as patients are concerned.
To return to the question of why this review is taking place, it is because errors were identified in respect of four cases and we believe the responsible thing to do is to look at all the work of that particular locum over the relevant period, which amounts to X-rays and CT scans on 4,590 patients. That is currently happening and will be completed as quickly as possible. It is being done simply for precautionary reasons. I hope it has the same positive outcome as the CT scan review in Portlaoise a few months ago when no new diagnosis was made, which was a very happy situation for all those patients.
Seymour Crawford (Cavan-Monaghan, Fine Gael)
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I want to ask another question.
Brendan Howlin (Wexford, Labour)
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I have called Deputy Tuffy. The Deputy had two sets of questions.
Joanna Tuffy (Dublin Mid West, Labour)
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In respect of the information given to me by the Minister in her last reply, I am not really clear on the month in 2007 that the HSE found out about this but it seems to have taken a few months to tell the Minister. In light of the issue that arose around Portlaoise at the time, the fact that she was not notified sooner was very unsatisfactory. Does the Minister have any comments to make in respect of that?
There have been previous cases of this type where the qualifications of locums have not been checked properly. This has happened on at least one occasion. Is the Minister taking any steps to ensure that the qualifications of locums are properly checked and that they have the required level of supervision?
The Minister said that the patients and GPs have been written to. In light of what happened in respect of Portlaoise and the need to ensure that the interests of patients are put first, will she put in place any additional information for patients? For example, will helplines be made available?
Mary Harney (Dublin Mid West, Progressive Democrats)
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In respect of the last question, in fairness to the HSE, the letter it wrote to the patients with the questions and answers, which will be very helpful to patients, is impressive. The HSE has also put in place a helpline and has been in constant engagement with the families of the four patients who passed away from lung cancer.
There are issues that arise for locums. Obviously, they must be registered as specialist registrars with the Medical Council. The new Medical Council is being appointed tomorrow with stronger powers in respect of competence assurance and so on, which is long overdue. The major issue for our hospital system is the fact that of the 6,000 doctors who work in our hospitals, 4,000 are non-consultants. Many of them are relatively junior doctors. This is why it is so important to get a new contract of agreement, the results of which I hope we will get tomorrow evening when the ballot is concluded and announced by the Irish Hospital Consultants Association, so that we can substantially increase the number of consultants working in the system based on a contract of employment that suits the needs of the public health care system and not the current contract which certainly does not meet the requirements.
In respect of the time issue, a review of 16,000 X-rays is being carried out at a hospital in France. One must decide what one will review and how one will do it. Among the medical expertise available in this country and supported internationally, there was a difference of opinion about whether it should be reviewed at all. The HSE has taken a precautionary view in the interests of patients and decided to review all of the cases and tell the patients that it was going to do it. It could have gone off and got some experts to look at all these X-rays and only written to patients subsequently, but it decided to be up-front and open, which I support. I think that has been a very good thing.