A woman who went into hospital for a knee operation which was unsuccessful could not find out the name of the surgeon who operated on her until she got her bill from the VHI.
The woman, who is an acquaintance of Judge Maureen Harding Clark who chaired the Lourdes Hospital Inquiry, was operated on earlier this year.
But when she returned to her hospital to find out why she had not got the relief from the operation which she had been expecting, staff could not locate her medical records.
"Nobody knew what had been done to her, there were no notes, the surgeon's notes were missing . . . no one was able to tell her what had been done to her knee but she was able to find out afterwards from her VHI bill the name of her surgeon and that she had had an arthroscopy of the knee," Judge Harding Clark said.
She added that the findings in relation to what happened to her were never explained to her by the hospital and she can't even go to a physiotherapist at the moment because the physiotherapist said he couldn't work on her until he knew what had happened to her during the operation.
Judge Harding Clark gave details of the incident when speaking at the graduation of students from UCD's graduate diploma in healthcare (risk management and quality) course.
Minister for Health Mary Harney was present for her address but Judge Harding Clark refused to name the hospital where the incident took place.
She urged the new graduates not to allow management of institutions to use them "as window dressing" and to pretend all was well just because they had a risk management graduate on the staff.
Meanwhile, in relation to the Lourdes Hospital Inquiry which looked at why an abnormally high number of Caesarean hysterectomies were allowed to be carried out unnecessarily at Our Lady of Lourdes Hospital in Drogheda for many years, Judge Harding Clark said what happened there was due to systems failures rather than a cover-up.
There was no culture of audit, no team work and no protocol of any kind for the identification or treatment of severe haemorrhage.
There was also a lack of leadership in the hospital where there was far more talk about raising money than raising standards.
"Hospital scandals are almost invariably multi-faceted and it's a rare day when the technical deficiencies of surgeons are the sole problem," she said.
However, she said the Lourdes Hospital maternity unit was now a changed place. It now had a leader and a deputy leader, an audit officer and a risk manager, and there was critical analysis of near misses, she said.
"Now the buildings are still inadequate and they've got a massive throughput of patients and staff," she added.
But she said a taskforce set up under Dr Eilis McGovern last year had identified the needs of the hospital which included more anaesthetists, more midwives and more computers and, as far as she was aware, the list of needs was "well received in the Minister's [ Ms Harney's] department".
However, she intimated it remained to be seen what the Department of Finance did with it.