THE DR ANN O'DOHERTY REPORT:The clinical review of mammography services at the Midland Regional Hospital in Portlaoise carried out by Dr Ann O'Doherty of Breastcheck found that the safety, quality and standard of many aspects of the breast imaging service there between November 2003 and August 2007 "fell well below achievable best breast imaging practice".
She said that this had resulted in a "significant and avoidable delay in the diagnosis of breast cancer".
Dr O'Doherty said that the false negative rate found in the hospital "on aggregate falls within the false negative rates published within similar reviews". However, she later said in a radio interview that the rate in Portlaoise was significantly higher than in other units with multi-disciplinary teams.
In her review she also criticised the quality of reporting on mammograms and breast ultrasound by radiologists at the hospital which, she maintained, "lacked clarity, specifity and helpful conclusions that could have directed clinical management".
THE JOHN FITZGERALD REPORT
The report by John Fitzgerald examined the management by the HSE of events following the decision to suspend the radiology service at Portlaoise and place a consultant on administrative leave. It looked at how the Minister for Health and senior HSE figures appeared to believe that there was just one review underway when in fact there were two, and how 97 women learned they were to be recalled for further tests through comments made in the course of an Oireachtas committee hearing.
The report found that while there was no suggestion of wilful neglect by any individual involved, there was a "fundamental weakness in the management and governance of the process from the outset because there was no authoritative co-ordination and management role established for the review process as a whole". It said that communication throughout the period was inconsistent and sometimes contradictory. It maintained that different people in the system seemed to have different understandings of what was going on. It concluded that "in the midst of the intense activity surrounding the review, "the needs of the patients potentially affected receded".
THE ANN DOHERTY REPORT
This report by senior HSE official Ann Doherty (right) looked at the circumstances that led to the suspension of breast radiology services at the hospital in Portlaoise in August 2007 and the decision to place a consultant radiologist on administrative leave. It found that in June 2007 a clinical nurse specialist in oncology/breast care had expressed concern to the director of nursing at the time patients had to wait for diagnosis. It said that this highlighted to her that there were cases of over-reporting of breast cancer. The nurse reported eight instances where radiological diagnosis differed from reports in Portlaoise and those carried out on the same patients in St Vincent's in Dublin. This was discussed at a meeting of HSE and hospital management in late August and a decision was taken to carry out a review of breast radiology services. The report reveals that three senior members of management had reservations about whether it was necessary to place the consultant on administrative leave but that one of these made "a judgment call" the following day that it was warranted in the interests of patient safety.