Muiris Houston: Missed cancer cases in Susie Long’s homeland

There is a horrible irony surrounding the missed cases of colon cancer in Wexford General Hospital and that is that the problem has arisen in the south-east of the country, where Susie Long, who died prematurely because of colonoscopy delays, lived and whose family has done so much to bring about improvements in the health system.

It could be argued that her and her family’s efforts encouraged those with symptoms of possible colorectal cancer to go to their doctor, but also hastened the introduction of BowelScreen, the national screening programme for people aged 60-69.

Run by the Health Service Executive's National Cancer Screening Service (NCSS), the screening programme began on a phased basis in 2012.

Fifteen screening centres were set up around the State, where people found to need further investigation after a home test are called for colonoscopy.

The screening cycle is repeated every two years, and while the uptake has been lower than expected, 5 per cent of those screened have been referred on for a colonoscopy.

Repeat testing

However, following the discovery that two patients who had a screening colonoscopy in Wexford General Hospital in 2013 were found to have bowel cancer in October and November 2014, alarm bells rang and 600 people have been recalled for repeat testing.

It now appears up to 13 cancers were missed, with one probable death.

Cases like this are referred to as “interval cancers” as they occur in the two-year period between screenings. While they cannot be eliminated, a quality screening programme is expected to have a very low rate of such malignancies. When they do occur, the entire clinical process must be scrutinised.

A colonoscopy involves having a flexible telescope introduced via the rectum into the bowel. The test relies primarily on the endoscopist visually examining the walls of the colon, right up to the point where it joins the small bowel. The doctor carrying out the test then takes a biopsy from any suspicious looking lesion they see. These biopsies are then sent to the laboratory, where they are examined by a pathologist who decides whether there is a cancer present.

Most bowel cancers are slow-growing and begin life as small polyps. The nature of the cancer means it is well-suited to a screening process. However, there is no test in medicine which is 100 per cent accurate; missed cancers are referred to as a false-negative result. False negatives occur for a number of reasons: human error on the part of the endoscopist or the pathologist; faulty equipment; failure to follow standard protocols; and poor training and monitoring of clinicians.

Recruitment

Questions must now be asked about how doctors and others were recruited by the NCSS. Were their abilities fully assessed prior to beginning work in the bowel screening service? Was their performance monitored? Did they receive sufficient structured ongoing training while in post?

It may be tempting to “blame and shame” an individual for the missed cancers. This would be a mistake.

Patients and families affected need full disclosure of the reasons for identified failures and must be given full sight of official reports. And all of us need to hear from the NCSS on how the remaining screening colonoscopy units are performing and the steps being taken to ensure they carry out their work to the highest standards.