A Beaumont Hospital error sparked a major investigation, writes Eithne Donnellan, Health Correspondent
TWO YEARS ago, while holidaying in Dublin, a 55-year-old English man, Louis Selo, collapsed and died. His body was taken to Beaumont Hospital for a postmortem examination, which would be normal in the case of a person's sudden death.
But what transpired in the autopsy room at the hospital on August 8th, 2006, became the subject of both an internal and external investigation after Mr Selo's body was returned to the UK a few days later.
As is customary when bodies are returned to the UK for burial, he underwent a second postmortem there. When the second postmortem was carried out at St Thomas' Hospital in London, the pathologist there was shocked to discover two hearts, four kidneys and two livers in his abdominal cavity.
At 2.30pm on August 14th, 2006, a consultant in Beaumont received a telephone call from the professor of pathology at St Thomas' Hospital. He said he had discovered additional organs in Mr Selo's body while performing a second autopsy that day.
The doctor in Beaumont contacted the senior anatomy pathology technician in the hospital, believing he had cleaned up after the two postmortems which had taken place in or about the same time at the hospital on August 8th - one on Mr Selo and one on an unnamed Irish woman.
On August 8th, 2006, the bodies of the two people undergoing postmortems in Beaumont were on two tables positioned end-to-end in the autopsy room, known as Table 1 and Table 2. There was also a dissecting bench alongside the tables, not divided by any screen but a pillar and scales at the centre served to demarcate the bench in two distinct halves.
Side A of the bench was used by the pathologist examining the body on Table 1 and Side B by the pathologist working at Table 2.
The senior technician said he went to the autopsy room to reconstruct the body of the female on Table 1 after her postmortem. The postmortem on the male body had been completed at this time but the body had not been reconstructed. There was nobody else present in the room. He collected the organs belonging to the body of the female, which were on Side A of the dissection bench and on Table 1. He put them in a bag inside the body, "then stitched the body and returned it to the fridge".
The independent investigation into what happened next, obtained by The Irish Times under the Freedom of Information Act, states that the senior technician then returned to the autopsy room to clean up. He noticed a tray of organs near the middle of the dissection bench on Side A. It passed through his mind they could belong to the body of the female but just as quickly he dismissed this idea as he could not see how he could have missed them when collecting the organs and reconstructing the body. He proceeded to put these organs into the body of the male patient which was then stitched up by a different technician and returned to the UK.
Inquiries began at Beaumont once it emerged organs had been misplaced. The senior technician who misplaced them owned up but gave a few different explanations as to how it happened. He first told a consultant it passed through his mind the organs belonged to the woman after she had been stitched up but he then dismissed the idea and put them into the man's body. Later in a written report he said by the time he realised his mistake the remains of the woman had been taken to a funeral home. And in a statement prepared for the hospital's internal inquiry, which his union assisted with, he said he didn't misplace the organs deliberately. He said the incident was not totally his fault as linking the identity of organs to bodies after postmortems was not easily performed "as there was no track and trace system in the postmortem room".
The independent report says the absence of any policy or procedure for tracking organs was a contributing factor to the misplacement of the organs. The hospital says it has now addressed this.
The report recommended hospital management address "the performance and competency issues of the personnel directly involved". Beaumont would not say if any member of staff had been fired, only that "appropriate disciplinary procedures" have been completed.
Meanwhile arrangements were made by Beaumont to have the Irish woman's organs transferred back from London and returned to her family here.
"Beaumont Hospital would not say if any staff member had been fired, only that disciplinary measures had been completed