Radiographer ‘mistook knee for elbow’ at Waterford hospital

A radiographer allegedly mistook a knee for an elbow in an X-ray image and exposed a young patient’s mother to radiation, a fitness-to-practise inquiry has heard.

Kashimbo Musonda is facing allegations of poor professional performance and professional misconduct in connection to events that transpired at University Hospital Waterford over a 2½-week period up to March 8th, 2017.

It is the first public fitness-to-practise inquiry by Coru, which regulates health and social care professionals.

Ms Musonda faces five allegations including a failure to display the skills or knowledge to safely practise as a radiographer.

In evidence to the committee at its offices in Dublin on Monday, Louise Diamond, the hospital's radiology services manager, described how concerns about Ms Musonda's skills had arisen almost immediately after her appointment on a six-month specified purpose contract.

Ms Diamond said her colleague Fiona Phelan, who had been assigned to "mentor" and observe Ms Musonda after earlier incidents, came into her office on March 8th, 2017, and told her an incident had occurred in the emergency department.

Ms Phelan had said she had left the room where Ms Musonda was carrying out an X-ray on a 12-year-old boy for a few minutes. When she returned Ms Musonda was about “to fire a fourth image” and the child’s mother was standing in the room without lead for protection. Ms Musonda asked the mother to stand behind the control panel, the fourth image was fired and the patient was returned to wait for the doctor.

Ms Diamond said what had happened was "not in line with best practice or our policies or procedures" and may also have to be reported to the Environmental Protection Agency.

Ms Musonda had initially told Ms Diamond that she had only taken one X-ray and began filling in the form for the State Claims Agency on that basis.

“She told me it wasn’t a big deal and that it could happen to anyone,” Ms Diamond said of the radiographer’s alleged failure to have the child’s mother move behind the screen in the room.

Ms Musonda later confirmed she had taken four images.

“She didn’t seem to understand the gravity of the situation,” Ms Diamond said.

Ms Diamond said she had waited almost two weeks to report the issue to Coru and that it was “not something I did lightly”.

“I had serious concerns for patient safety. That’s my overriding concern,” she said.

Ms Diamond said she believed she had “a duty of care to patients around the country to report what had happened during her time in Waterford”.

Identification

Radiographer Keelin Kavanagh claimed Ms Musonda had allegedly failed on a number of occasions to carry out a three-point identification check in which patients would be asked to confirm their name, address and date of birth before an X-ray.

She said there was another occasion where there was an image on the screen “and it was an image of a knee and Ms Musonda was under the impression that it was an elbow”.

She agreed, however, that Ms Musonda may have only looked fleetingly at the image.

Counsel for Coru Eoghan O’Sullivan said Ms Musonda’s shortcomings were numerous and varied.

Ms Musonda is not in attendance or represented at the inquiry but has denied the allegations and said in correspondence that she was saddened they had been made by colleagues.

In an email to Coru's legal team on Monday, Ms Musonda said that with "deep sadness in my heart" she had been made the subject of "public ridicule" through the reporting of the story online in Ireland.

She did not address the committee’s question to her, through the lawyers, about whether she wished to participate by telephone.

She also indicated she was in Lusaka in Zambia waiting for a travel visa to be processed by the Naturalisation and Immigration Service in Dublin to attend the inquiry, which continues on Tuesday and Wednesday.