A series of reports into how nine women were mistakenly given the all clear for breast cancer has found "significant and avoidable" delays in diagnoses as well as mismanagement that "heightened anxiety and uncertainty" for the women affected.
A clinical study of mammography services at Midlands Regional Hospital in Portlaoise was carried out by Dr Ann O'Doherty, who said services given to patients between November 2003 and August 2007 fell well below best practice.
Dr Ann O'Doherty
Breast cancer services were suspended and a clinical review of more than 3,000 mammograms commenced late last year after it emerged a number of women had been misdiagnosed. A total of nine women were found to have cancer after they had initially been told they were clear.
Dr O'Doherty's report concluded that best practice in breast imaging services was not adhered to at Portlaoise Hospital, including the way images were processed, the absence of triple assessment and diagnostic multidisciplinary meetings.
"As a result the safety, quality and standards of many aspects of the service fell well below achievable best-breast imaging practice and this resulted in a significant and avoidable delay in the diagnosis of breast cancer," the review says.
The HSE apologised in a statement for the misdiagnoses which were due to "shortfalls in clinical quality standards at Portlaoise hospital".
HSE chief executive Prof Brendan Drumm said: "What happened here is horrendous to the individual women and to this organisation."
A second report carried out by John Fitzgerald for the HSE board, published earlier today, examined the management of all events following the decision to suspend the services in Portlaoise.
Mr Fitzgerald, a former Dublin city manager, criticises "inconsistency and lack of clarity" in information released by the HSE to the press, with an "ongoing" release of the numbers of patients affected.
"The 'drip-feed' of numbers could only have heightened anxiety and uncertainty for those patients potentially affected," the Fitzgerald report says. He says information about the numbers of women involved in the review, released by HSE chiefs at an Oireachtas committee on November 22 nd, led to "a degree of hysteria" in the media and "undoubtedly cause more concern for the women potentially affected by the review".
Mr Fitzgerald says the HSE approach contributed to "heightening confusion and adverse media comment".
In his view, numbers should not have been released at any stage in the review process until the whole review process was completed.
"I am concerned that sometimes the needs of patients can be compromised in the face of the constant pressure to provide ongoing information before the completion of such a review process," Mr Fitzgerald says.
"I believe that there was a fundamental weakness in the management and governance of this process from the outset, because there was no authoritative co-ordination and management role established for the review process as a whole."
Mr Fitzgerald concludes that the communications difficulties "cannot be separated from the weakness of management and governance in the process. In the midst of the intense activity surrounding the review, the needs of patients potentially affected receded".
At no point in his review had he identified "any suggestion of wilful neglect by any individual/s involved in the process" but rather that many people were working under "significant pressure".
Minister for Health Mary Harney today reiterated her apology to the nine women identified in the clinical review who had a delay in their diagnoses of cancer.
"We need to strengthen the governance and management of serious incidents by the HSE. I welcome the steps already initiated by the board. These include the preparation and implementation of a new serious incident management protocol and a clear process for managing all aspects of a response to any future serious incident," she said.
The Minister has asked the HSE board to adopt an interim serious incident protocol immediately.
A third report by Ann Doherty, acting head of the National Hospitals Office at the HSE, deals with the background to the decision to suspend the breast radiology services.