4thNovember 2008
This Review of Chest X-Rays and CT Scans carried out at Louth Meath Hospitals was initiated when it was discovered that a small number of patients who later died from lung cancer had their initial diagnosis of cancer delayed as result of missed diagnoses.
The look back review re-assessed all of the chest x-rays and CT scans reported by a locum consultant radiologist while he worked at Drogheda and Navan Hospitals from August 2006 to August 2007.
The look back review was carried out to identify any possible significant ongoing patient safety issues, and to provide reassurance to those patients whose chest x-rays and CT scans were assessed by the locum consultant that they had been correctly diagnosed and treated.
The main finding of the look back review was that 9 patients had their diagnosis of cancer delayed by some months as a result of radiological missed diagnoses. All of the patients whose diagnosis was delayed had their cancer diagnosed before the look-back review began. The look-back review did not find any undiagnosed cases of lung cancer
The look back review acknowledges that the delayed diagnoses had varying impacts on these patients' care and treatment options. These included lost opportunities in relation to cure prospects, additional life-span and earlier palliative care. It led to worry, uncertainty and distress for families and reduced the time available to them to come to terms with the serious diagnosis and the impending death of their family member.
During the course of the review two cases of tiny probable lung tumours were discovered in patients scanned for other reasons arising from the review. These tumours, which were found on new radiographic examinations, were not present or visible, even in retrospect, on the previous examinations. Therefore these cases were not the subject of a missed diagnosis. They represent interval tumours and represent new disease arising between the original and subsequent radiographic examinations. Interval tumours are a well recognised phenomenon arising where patients have sequential radiographic examinations.
Stephen Mulvany, Hospital Network Manager said ‘At the core of these events are the patients involved and their families. The HSE wishes to apologise to the families of the patients who were harmed by these delayed diagnoses, and to all patients included in the review. While the events cannot be reversed,we are unequivocally committed to providing an open and honest record of what happened, and to doing what we can to avoid a recurrence of similar events.’
‘Communicating with the patients concerned during this review was always a priority for us and has been ongoing since the review commenced. Louth Meath Hospitals have been in contact with all the patients concerned over the last few months as their review results have become available, andthere have been individual meetings and ongoingcommunication with the families of the patients who had their diagnoses delayed’.
He concluded that 'Louth Meath Hospitals took the best advice available when deciding to carry out this look back review and what methodology should be used. This included discussions with HIQA, the Department of Health and Children andUK radiology experts.’
In response to the matters described in this report, HSE North East Hospital Network is adding to its existing patient safety measures by beginning an additional project to enhance Clinical Governance in the Radiology Service in the Hospital Group. A good system of clinical governance within healthcare involves quality assurance systems aimed at reducing the likelihood of errors occurring and increasing the likelihood of early detection of those errors which do occur. This project will cover the five hospitals in the North East and will produce an agreed programme to improve clinical governance, and therefore patient safety and quality of care.
The report is available to download at the link on this page.
