ANALYSIS:The report on Tallaght hospital X-ray controversy highlights important ethical issues
THE PUBLICATION of the Hayes report into critical patient safety issues at Tallaght hospital brings some closure to a saga which highlighted how patient X-rays were left unreported and, as a separate problem, referral letters from local GPs were inadequately processed over a period of years.
Last March it emerged that a prominent Tallaght GP, Prof Tom O’Dowd, had expressed concerns to both the Health Information and Quality Authority and Tallaght hospital management about patient referrals being processed either tardily or not at all. It also emerged that delays were experienced in receiving timely X-ray reports from the hospital; subsequently it transpired a massive backlog of unreported X-rays had built up within the hospital.
It’s worth reiterating the specific case that led to Prof O’Dowd raising the alarm. In a letter to the acting chief executive of the hospital, dated January 22nd, 2009, he said he was concerned about the case of “a young woman whose mole I excised that needed wider dissection and whose urgent referral letter got lost in the system”.
The woman was subsequently diagnosed with skin cancer. She had returned to the practice when a referral to a surgical consultant at Tallaght did not prompt an outpatient appointment and she had to be re-referred by her doctor to another hospital for treatment.
The referral of a patient from primary to secondary care is at the core of our health system. It frequently involves a decision by a GP that a patient he has seen has either symptoms or clinical signs suggestive of serious illness such as cancer or heart disease.
The next step is to write a referral letter to the appropriate consultant in an acute hospital. In this case, the doctor will label the referral urgent and will detail why he thinks the person needs prompt investigation. The consultant reviews the letter – within 48 to 72 hours of receipt – and arranges for a confirmed appointment to be sent to the patient.
Hayes has identified a particular outpatient problem at Tallaght. Because an electronic diary system could not offer appointments beyond a 12-month timeframe an ad hoc process of “queuing to queue” developed.
These referrals ended up being stored in boxes in administrative areas and were no longer part of the main appointment system. Worryingly, the report says “this feature currently affects outpatient (OPD) clinics in a number of specialties including adult elective orthopaedics, ENT surgery, ophthalmology, urology, neurology, dermatology and rheumatology.”
Although Tallaght GPs pointed to delays in other hospital departments, according to Hayes, orthopaedics was central to the GP referral letter failures. He concludes orthopaedic consultants at Tallaght had decided not to accept new OPD referrals because of difficulties admitting patients for planned surgery.
And while we are told no adverse events had affected those patients caught up in the backlog, the report notes: “The proposition that services should be withheld from one group in order to safeguard the treatment of others, even for the best motives, does seem to raise important ethical issues which require the most careful consideration.”
What about the backlog of unreported X-rays? Hayes traced it back to 2003.
Certain efforts were made to deal with the issue but none was definitive.
The review identifies 57,921 unreported X-ray films; all have now been reported with “no significant abnormalities, as well as no unrecognised malignancies” identified.