The news that University Hospital Kerry is reviewing some 46,000 Radiological Images related to more than 26,000 patients has understandably sparked huge concern amongst patients and their families. The images include X-rays, CAT scans and ultrasounds carried out between March 2016 and July 2017. Initially concerns emerged following complaints by a number of General Practitioners and Consultants but the decision to undertake a review came about after three Serious Reportable Events were discovered over the summer.
It appears that all the scans being reviewed relate to work carried out by one individual Consultant Radiologist who is no longer employed by the Hospital and has been reported to the Medical Council. It is understood that the individual has previously worked in another Irish Hospital in 1990 and 2006.
Dr. Claire O’Brien, Clinical Director at University Hospital Kerry advised that the review of the scans was commenced at the end of October 2017 and to date 18,000 scans have been reviewed. The number of serious delayed diagnoses arising from the scan review to date has increased from three to seven. However, more than 28,000 images still need to be reviewed and the process is expected to take a further 8 to 10 weeks.
Once again, this debacle underlines the need for a statutory duty of disclosure here in Ireland rather than the voluntary Open Disclosure scheme which has been proposed by Minister for Health Simon Harris earlier this year. A statutory duty of disclosure is simply a responsibility on hospitals, medical and nursing staff to tell the truth to patients when there has been a mistake.
Notwithstanding that the HSE has had a national Open Disclosure policy since November 2013, affected patients from University Hospital Kerry were not individually notified that their Images were being reviewed. In my view it is not acceptable that patients were not informed of the review and were first made aware of it by reports in the media in recent days, many months after the problems were first discovered. Patients who had radiological investigations carried out at the hospital during the period in question face significant worry over the coming weeks wondering whether their image was reviewed by the Consultant Radiologist in question and whether any positive scan results were in fact false.
The scan recheck raises questions surrounding protocols, processes and oversight, not just in University Hospital Kerry but in all hospitals across the country.
In August 2017 it was announced that at least 25,000 X-Rays, MRIs, CTs and ultrasounds taken since 2011 and held at the HSE’s National Integrated Medical Imaging System (NIMIS) may need to be redone after a technical “glitch” was discovered.
Unfortunately, in the recent past we have seen the serious impacts of cancer misdiagnosis in Wexford General Hospital where twelve cases of bowel cancer were missed from a recall of 600 patients who had received colonoscopies at the Hospital in 2013/2014 and which sadly resulted in the death of one patient.
Hopefully lessons will be learnt from this latest debacle and it will not take a further scan scandal or serious misdiagnosis in another hospital for changes to be implemented.
Karen Bohane, Medical Negligence Solicitor, Cantillons Solicitors
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