Jan O'Sullivan (Limerick East, Labour)
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Question 95: To ask the Minister for Health and Children the reason the report into the misdiagnosis of X-rays and CT scans in the north east does not contain recommendations; the reason there was no patient representative on the review panel; the reason there is no explanation of the errors in diagnosis that were made; the way 29 patient X-rays or case files went missing; and if she will make a statement on the matter. [42037/08]

Mary Harney (Dublin Mid West, Progressive Democrats)
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On 4 November the Health Service Executive published a Review of Chest X rays and CT scans reported by a Locum Consultant Radiologist from August 2006 to August 2007. The review was prompted by concerns that a small number of patients in two Louth Meath Hospitals had their diagnosis delayed, due to an abnormality on their chest X-ray not being identified on initial reporting.

This review took the form of a clinical look-back. It was carried out to identify any possible ongoing patient safety issues and to provide reassurance to those patients whose chest X-rays and CT scans were assessed by the consultant whose work prompted the review. The methodology of the review was developed to identify ongoing harm or disadvantage to patients and allow for any additional care or treatment required to be delivered.

The interests of patients were represented on the Review Team by the HSE's Head of Consumer Affairs. Communications with patients were a priority for the Review Team. The families of the nine patients who were identified as having a delayed diagnosis of lung cancer each received individual reports prepared by Prof Muiris Fitzgerald. These individual reports set out the clinical significance of the delayed diagnosis. Prof Fitzgerald also met with each of the families and relayed their concerns to the HSE.

The Report noted that despite extensive searches 29 out of almost 6,000 X-rays and CT scans could not be found. These patients were followed up. In some cases a subsequent similar radiograph was examined. In the remaining cases patients were offered new examinations. One person who was not an Irish resident could not be traced from the contact details held by the hospital.

While the Report did not issue formal recommendations it set out actions to be taken by the HSE on foot of the findings of the Review. These actions include:

Improving Quality and Patient Safety in the North East Hospitals: The HSE has initiated a project to enhance clinical governance within radiology services in the North East. Work has already commenced and it is envisaged that an action plan will be completed next month.

Referral to Professional Bodies: The report has been referred to the Medical Council of Ireland and has been copied to the General Medical Council in the UK.

Recruitment of Locum Consultants: The HSE has stated that there will be full compliance with the new national guidance in relation to the level of and recruitment of locums in medical practice, which was issued in May, 2008.

It is important to note that diagnostic radiology is not a precise, error-free science. It is a multi-step process where high-tech imaging is used to assist health professionals in the diagnosis of a range of conditions. International studies suggest that the incidence of discrepancies and errors in general radiology practice lies between 2% and 20%. This range of errors is a worldwide phenomenon and includes all radiology departments. This review was designed to identify patients who may need additional care, not to assign blame or culpability to a particular physician. Clinical governance within healthcare systems reduces the likelihood of errors occurring and increases the likelihood of detecting those errors which do occur. The HSE North East Hospitals are fully committed to driving change and, in partnership with its clinical staff, doing all it can to enhance patient safety at all levels.