A summary of the findings of the Health Information and Quality Authority report into cancer services at University College Hospital Galway (UCHG).
• The 18-month delay in diagnosing a 51-year-old Tipperary woman with breast cancer was as a result of mistakes made by two consultant pathologists in the laboratory of University College Hospital Galway (UCHG). Both wrongly gave her the all clear.
• The woman had been attending Barringtons private hospital in Limerick and if there had been a multidisciplinary team meeting between the pathologists at UCHG and staff in Barringtons, the errors might have been picked up.
• The absence of such an arrangement was "a significant contributory factor in her delayed diagnosis".
• The report says these multidisciplinary team meetings must be held in both public and private hospitals treating cancer.
• The work of the first consultant pathologist in UCHG who wrongly gave the woman the all clear in September 2005 had his work reviewed and no other errors were found.
• The second pathologist from UCHG, a locum from Finland, who gave her the all clear in March 2007, also had his work reviewed and a significant number of other mistakes were found. Twelve other patients whose samples he analysed were given either a delayed diagnosis or had investigations delayed as a result of his errors. His error rate was five to six times the norm.
• The UCHG pathology department was relying on the use of temporary and locum consultant staff during the period under review because of difficulty recruiting permanent staff and the long time lag between the needs of the service being identified and the appointment of additional staff.
• The hospital had no specific procedures for the recruitment of temporary and locum consultant staff.
• The report recommends a formal policy for the recruitment of locum and temporary consultant staff should be established and implemented nationally.
• It found there was no evidence the pathology errors in the Tipperary woman's case were as a result of a shortage of resources.
• Pathology staff at UCHG have cramped and outdated working conditions.
• The IT systems to underpin data collection in the pathology department at UCHG are poor.
• The symptomatic breast disease service at UCHG was found to be well functioning, but on occasion there can be long waiting times at its outpatient clinics.
• UCHG needs to strengthen governance arrangements for working with third parties.
• The report recommends the HSE appoints one person to ensure its recommendations are implemented.