AN INVESTIGATION into the misdiagnosis of breast cancer patient Rebecca O'Malley has found that an error made at the laboratory of Cork University Hospital where her biopsy was misread in 2005 might have been picked up at her local hospital in Limerick had proper procedures been in place there, writes EITHNE DONNELLAN, Health Correspondent.
The inquiry by the Health Information and Quality Authority (HIQA), published yesterday, found a locum consultant pathologist at Cork University Hospital had wrongly reported that her biopsy was benign.
"This in itself may not have led to a delay in treatment for Rebecca O'Malley had a fully functioning multi-disciplinary team meeting to discuss her case taken place" at the Mid Western Regional Hospital in Limerick, it said.
The report says there was no imaging or clinical evidence to suggest the tumour that had been analysed in Cork was benign and if this had been discussed at a meeting of the full team caring for Ms O'Malley - the breast surgeon, radiologist and pathologist - it might have been spotted.
It said there was a "missed opportunity to correct the interpretative error".
Because the pathologist was in Cork, this doctor was not at the multi-disciplinary team meeting. The review group recommends video-conferencing be used in such cases.
In the end Ms O'Malley (41), a mother of three from Ballina, Co Tipperary, experienced a 14- month delay in having her breast cancer diagnosed.
The report of the investigation says the pathologist who wrongly reported on her biopsy worked at Cork University Hospital from July 2004 to August 2005. The inquiry team audited this pathologist's work and found no other errors had been made.
The inquiry team also decided to look at the care given to 24 more patients attending the Limerick hospital whose biopsies had been sent to Cork. They found seven had not been given ultrasounds and in September 2007 told Limerick hospital it was calling them back as a precautionary measure.
One of the women recalled, had already gone to her GP in July 2007 and was awaiting an appointment at Limerick hospital, when the inquiry team suggested she be recalled. Ultimately she was found to have breast cancer and had a mastectomy.
The inquiry team found that she had not been misdiagnosed on the basis of a review of original tests she underwent in 2005.
However this woman expressed concerns to the inquiry team about delays in her being seen once she was referred back to Limerick hospital by her GP in 2007.
The inquiry report levels significant criticisms at both the Cork and Limerick hospitals. It criticises the level of communications between them, the under-developed and ineffective management systems within them, the way fine-needle biopsies were carried out in Limerick and the way slides were prepared for analysis in Cork.
It also found ineffective engagement between senior management and clinical staff. There are also serious criticisms of the HSE.
The report said local managers did not appear to have sufficient authority vested in them to make decisions about priorities and there were often long delays in getting responses to letters sent within the management system, if a response was issued at all.
"The impression gained was of a system that delayed or avoided difficult decisions."
The report shows that even when Ms O'Malley raised concerns about her misdiagnosis with the hospitals in 2006 there was no great rush to find answers for her as to what had happened. She had to do the running.
The investigation team also drew attention to resource issues. It said there were issues over staffing in Limerick, one of the eight new designated cancer centres, and staff reported spending a lot of time engaged in activity aimed at securing the resources they needed to deliver services.
Dr Tracey Cooper, chief executive of the Health Information and Quality Authority, said all hospitals should read the report and if they had gaps in services they should address them.
Asked if the Limerick and Cork hospitals were safe, she said recommendations had been made in the report and it was the duty of the HSE to implement them.
Chronology of events in Rebecca O'Malley case
1st March 2005:
She attended a GP and an abnormality in her left breast was noticed. She was referred to the Mid Western Regional Hospital, Limerick.
15th March 2005:She had a mammogram and ultrasound
in Limerick and both were reported as
normal. But a fine needle biopsy was taken and sent to the
laboratory at Cork University Hospital (CUH) for analysis
8th April 2005:She was informed the results of the biopsy had come back as normal
29th March 2006:She attended her GP on another matter but the GP referred her back to Limerick on examining her breast
May and June 2006:Two further biopsies were performed in Limerick
8th June 2006:She was informed invasive cancer was present and a mastectomy was recommended
17th June 2006:She had a mastectomy in London
27th October 2006:She wrote to her surgeon in Limerick requesting information on how the diagnosis of her cancer had been missed in 2005
16th November 2006:She met with Limerick hospital and asked for the results of her original tests to be re-examined
22nd January 2007:CUH, having reviewed her biopsy told a surgeon in Limerick, there was evidence of malignancy in the original sample
31st January 2007:A Dublin hospital, which also reviewed the original samples, agreed an error had been made
15th March 2007:She wrote to Limerick hospital looking for results of the reviews of her tests
4th April 2007:A meeting was arranged at Limerick hospital where Rebecca was told a misdiagnosis had occurred. She asked for an independent review of how this happened
19th April 2007:She wrote to Limerick hospital saying if she did not receive adequate assurances that matters were being addressed within 10 days she would make her concerns public