Drogheda hospital plagued by litany of safety failures

ANALYSIS:The McEneaney report was not the first review of worrying practices at Our Lady of Lourdes

THE TREATMENT of Sharon McEneaney at Our Lady of Lourdes Hospital in Drogheda called into question “the standards of care and the safety culture and priorities in the hospital”, the review into her care found.

It uncovered a litany of failures in the treatment of Ms McEneaney from October 2007 to July 2008. But it was not the first review into practices at the hospital.

Among previous reviews was an investigation into the high rates of hysterectomy procedures carried out by disgraced obstetrician Dr Michael Neary. Judge Maureen Harding Clark carried out a study of systems at the hospital in 2005 after Dr Neary was struck off the medical register. Her report was published in 2006 and made strong recommendations about patient safety.

Another major review was undertaken after the death of 34-year-old Garda sergeant Tania McCabe and her son in 2007. Ms McCabe died hours after giving birth at the hospital. Further patient safety recommendations were made.

Last year, a report into miscarriage misdiagnosis nationally was published. It had been prompted by the experience of Melissa Redmond who was mistakenly advised by doctors at Our Lady of Lourdes that her pregnancy was no longer viable. A second opinion showed the baby was alive and well.

Ongoing legal proceedings are also under way in relation to the behaviour of a retired doctor at the hospital. And separately, the Health Information and Quality Authority has examined safety issues there.

The McEneaney report found “poor administration and organisational skills” had compromised Ms McEneaney’s treatment and her “slow progress through the diagnostic process was significantly hampered by poor medical record-keeping”.

They found there was a lack of a cohesive medical record-management system, and “poor” adherence to medical record-keeping policies.

There was “a tolerance of poor discharge planning and practices” and an absence of written communications with Ms McEneaney’s GP, apart from discharge summaries, two out of three of which “contained erroneous information and were written by doctors who appeared to have no direct knowledge of Ms McEneaney or her condition”.

The report found that the environment the obstetrical and gynaecology secretaries worked in was “not conducive to good administrative processes”. And there was “a level of resignation on behalf of those responsible for administration staff in accepting a poor working environment, sub-optimal staffing levels and administrative standards”. It also raised concerns about the administrative and organisational skills of Dr Etop Akpan, Ms McEneaney’s consultant obstetrician. And it said “follow through” for her treatment was lacking.

The review team acknowledged “a strong commitment from management” around quality and safety, “but little evidence of tangible outcomes” or that “a safety culture is engendered in routine clinical practice”.

It did also say the establishment of clinical governance structures within the hospital group and the appointment of two clinical directors “should facilitate the change required towards the development of a meaningful and sustained safety culture at the hospital”.

And it said the commitment of the McEneaney family to achieving future high standards for patient safety at the hospital was “impressive and commendable”.

It made 37 recommendations and said “significant resources” were likely to be required to fully implement the safety changes. The HSE said 31 of the report’s recommendations had been completed and a further five were under way. Dr Akpan’s clinical workload had been reduced and he had been stood down from “certain management duties pending satisfactory completion of an appropriate management programme”, it said. He was also not now acting in the lead colposcopy role.

The Medical Council declined to say what sanction had been imposed on Dr Akpan.

A spokesman for Patient Focus, which supported Ms McEneaney’s family through the fitness-to-practise process, called for all of the recommendations in the report to be acted on by all relevant parties without delay. He also called for all findings and sanctions in fitness-to-practise inquiries to be made public in an appropriate manner.