Investigation Report into the care received by Rebecca O’Malley, Symptomatic Breast Disease Services at the Mid Western Regional Hospital Limerick and the Pathology Services at Cork University Hospital
The Health Information and Quality Authority (HIQA) today published the report of its investigation into the care received by Rebecca O'Malley, following her presentation in 2005 to the Mid Western Regional Hospital (MWRH) Limerick with symptomatic breast disease, symptomatic breast disease services at the MWRH and the pathology services at Cork University Hospital (CUH).
The Board of the Authority, having given very careful consideration, approved the Report of the investigation team at a Board Meeting and authorised the publication of the Report.
The main finding of the investigation is that the error in diagnosis of Rebecca O'Malley was the result of a once off interpretive error by a locum Consultant Pathologist in CUH. The investigation found that this in itself might not have led to a delay in diagnosis for Rebecca O’Malley had a fully functioning multi-disciplinary review meeting about her case been held at the MWRH. This did not happen and an opportunity to correct the error was lost.
The investigation also highlighted serious issues with the manner in which the Health Service Executive (HSE) and its hospitals, MWRH and CUH, responded to Rebecca O'Malley's concerns as well as communications issues within and between the two hospitals and the wider HSE.
Dr Tracey Cooper, Chief Executive of the Authority said, "The findings and recommendations of this investigation are significant. They not only provide much needed answers to Rebecca O'Malley in relation to what went wrong with her care and experience, but also make clear recommendations for local and national improvements in the quality of symptomatic breast disease services, pathology services and a number of accountability, governance and communication requirements that are fundamental to providing safe healthcare.
"There are important lessons for those responsible for providing services and, when the recommendations contained within the Report are implemented, the Authority believes the experience of Rebecca O'Malley should not be repeated".
Dr. Michael Durkin, head of the investigation team said, "The investigation team conducted interviews with 35 people during the course of this investigation. We also undertook a detailed review of documents, policies and procedures at MWRH and CUH, site visits and reviews of patient records, imaging material and pathological specimens.
"Key themes emerged including: no fully functioning multi-disciplinary team meetings to review cases in the MWRH; poor quality cytology specimens being sent to CUH for review; significant shortcomings in communication within and between the hospitals and corporate HSE leading to a disjointed and delayed response to Rebecca O'Malley and a lack of accountability, cohesion and focus on the needs of Rebecca O'Malley in responding to her concerns. These were a symptom of systemic problems of under-developed and ineffective management systems within the hospitals".
Dr Durkin paid tribute to Rebecca O'Malley for her courage and persistence in seeking the truth about her misdiagnosis so that others would not share a similar experience. "Valuable lessons have been learnt and all hospitals providing breast cancer services should review their own services against the recommendations made in this Report. We accept that no diagnostic system anywhere in the world can be without error and this is why measures to minimise the chance of errors resulting in misdiagnosis are so important."
The investigation team has made 15 recommendations which it believes must be implemented by the HSE in order to safeguard the delivery of a quality service to patients. As a result, the Authority strongly recommends that the senior management and clinical teams of all hospitals who are providing symptomatic breast disease services should read this report, undertake their own baseline assessment against these specific recommendations and make the necessary changes in addressing where gaps exist.
Dr Cooper concluded; "The Authority will expect the HSE to performance manage the respective hospitals against the implementation of these recommendations and consider, at an HSE Corporate level, where the recommendations should be applied nationally. The Authority will agree with the HSE a timeframe for the Authority to periodically monitor that the recommendations are being implemented."
Marty Whelan, Head of Communications and Stakeholder Engagement
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