A woman whose diagnosis of breast cancer was delayed due to an error at the laboratory where her biopsy was read, has welcomed a report published by the Health Service Executive which commits to addressing the problems that led to her misdiagnosis.
Rebecca O’Malley (42), from Co Tipperary, had her breast cancer diagnosis delayed by 14 months after a laboratory error was made at Cork University Hospital in 2005. She subsequently had a mastectomy at a clinic in London in 2006.
In a report published on its website, the HSE has commited to ensuring ‘triple-assessment’ diagnostic procedures for patients with a potential cancer diagnosis on their first visit to all cancer centres by the end of this year. It also says additional staff are currently being recruited.
Such triple-assessment involves clinical examination, imaging by ultrasound and/or mammography and pathology sampling.
The HSE has also committed to ensuring, by the end of September this year, that multi-disciplinary team meetings are held at least weekly in the case of patients with a cancer diagnosis.
An investigation into Ms O’Malley’s case by the Health Information and Quality Authority (HIQA) published in April found that the error in made in 2005 might have been picked up at her local hospital in Limerick had proper procedures been in place there.
HIQA made 15 recommendations in its report, all of which were accepted by the Government. Then taoiseach Bertie Ahern said it was for the HSE to make sure they were implemented.
The HSE yesterday published an implementation plan for the HIQA report on its website and again apologised to Ms O’Malley for the errors in her case.
Ms O’Malley today welcomed the HSE implementation plan.
“When the HIQA report was published on 2nd April 2008, many people told me that the report would lie on a shelf and the recommendations would be quietly and quickly forgotten,” she said in a statement.
“I refused to accept that cynical but understandable response and I have remained determined to see the 15 highly important recommendations implemented in full.
Yesterday’s highly visible publication of the implementation plan by the HSE is evidence that essential changes are beginning to occur and that patients will eventually benefit from safer care and treatment in respect of symptomatic breast disease.”
Ms O’Malley said that in publishing the plan on its website, the HSE had demonstrated “greater openness, transparency and, above all, an acceptance of accountability for patient safety”.
“I hope this kind of publication will become a regular feature in future communications by the HSE. I will be following closely the progress made by the HSE towards the full implementation of the recommendations and I await with interest the publication of their next update.”
In its plan, the HSE sets targets for each of the HIQA recommendations, or outlines where steps have already been taken to address the issues.
The HIQA investigation in April found a locum consultant pathologist at Cork University Hospital had wrongly reported that Ms O’Malley’s biopsy was benign.
"This in itself may not have led to a delay in treatment for Rebecca O'Malley had a fully functioning multi-disciplinary team meeting to discuss her case taken place" at the Mid Western Regional Hospital in Limerick, it said.
The report says there was no clinical evidence to suggest the tumour that had been analysed in Cork was benign and if this had been discussed at a meeting of the full team caring for Ms O'Malley - the breast surgeon, radiologist and pathologist - it might have been spotted.
It said there was a "missed opportunity to correct the interpretative error".