Case shows Drogheda hospital had not learned from failures

Our Lady of Lourdes Hospital has been at the centre of a series of medical controversies during the past decade, of which the HSE's apology for the substandard care given to the late Sharon McEneaney is but the latest.

Previous reviews revealed the high rates of hysterectomies carried out by disgraced obstetrician Dr Michael Neary and shortcomings in the care of 34-year-old Garda sergeant Tania McCabe, who died in the Drogheda hospital hours after giving birth.

There was also the case of Melissa Redmond, who was mistakenly advised by doctors at the hospital that her pregnancy was no longer viable.

The hope – and it is an ambitious hope – is that Ms McEneaney’s death will be the last controversy to afflict the hospital and its patients.

For that to happen, the health service has to show that it is learning where mistakes are made. Some degree of accountability where staff are found to have erred would also help.

Failings
The failings in Ms McEneaney's case were apparent and largely undisputed. She first went to the hospital's emergency department in October 2007 with abdominal pain.

A month later, she was admitted to the hospital where a scan showed up a mass. This was removed in December but a biopsy was only taken in late June 2008. She was treated for cancer in July, but died the following year.

The HSE’s report into her death acknowledged that the hospital had “completely failed her”. But five years after her death, and four years after the publication of this report, its recommendations have not been fully implemented.

The hospital has yet to complete the job of improving communications with GPs, and efforts to improve clinical audit are ongoing. Improvements to record-keeping, including the provision of a single record for each patient and a move to electronic storage, have yet to be completed nationally.

Monitoring system
The first recommendation in the HSE report called for a national process to ensure all recommendations of reviews are implemented, as well as a monitoring system to ensure this happens.

But even though this recommendation is deemed to be implemented, the HSE has decided there will be no national monitoring of recommendations “per se”. Instead, the person who commissions a review is responsible for ensuring that recommendations are implemented. Only time will tell whether this proves effective.

Ms McEneaney’s case bore the hallmarks of systemic failure and showed the hospital had not learned all the lessons of previous adverse events.

The HSE report questioned the standards of care and the safety culture at Our Lady of Lourdes. But it also raised concerns about the administrative and organisation skills of Dr Etop Samon Akpan, the consultant obstetric gynaecologist in charge of her care.

In 2012 the Medical Council found Dr Akpan, who qualified in Nigeria in 1985, guilty of poor professional performance.