One of the most basic features of a properly run business is effective record-keeping. Without it, administration suffers and it becomes impossible to ensure accountability. Where lives are at risk - as in a hospital - fatalities can occur.
A missing medical file featured in the out-patient care of nine-year-old Frances Sheridan at Cavan General Hospital last year. Had the file concerning her earlier operation for appendicitis been available, the death of the young girl might have been avoided. In much the same way, had a consultant been asked to advise on the case, the outcome might have been different.
These uncertainties were compounded by the fact that a letter from her GP, correctly diagnosing her condition, was not made available to the surgical team on call. X-rays were taken, however, which showed no anomaly. In the light of such imponderables, last Thursday's inquest finding that death was due to natural causes, was extraordinary. The six-person jury ignored advice from the coroner that a verdict of misadventure would be the most appropriate finding. It may be that local jury members were excessively anxious not to suggest blame in this case, either in relation to the hospital or to staff members. Cavan General Hospital has had a bad press in recent years. It was described as "dysfunctional" in one report and local people are understandably defensive.
Certainly, the jury reached a unanimous verdict in a matter of minutes, based on the evidence of State Pathologist Marie Cassidy that the bowel might have become trapped intermittently over a number of days - perhaps excluding the time of medical examination - before finally causing death.
Inquests are not designed to apportion blame. They merely deliberate on the likely cause of death. And, in this case, the cause of death - a trapped bowel following an operation for appendix - could hardly be attributed to natural causes. The jury's verdict may reflect a general defensiveness by the public in relation to their local hospitals. But that kind of attitude militates against the kind of radical reform that is required and the introduction of best practice.
In Cavan, it was "a frequent thing" for hospital files to be missing when required. The standard of training for junior doctors could be improved. And the quality of general cleanliness left a great deal to be desired. Cavan hospital was not alone in this. And the Health Service Executive faces an uphill task in providing quality hospital care for the public. Reform will, inevitably, involve unpopular decisions and the centralisation of expensive facilities. It should get on with it.