THE DEATH of Ann Moriarty is not just a tragedy. Her treatment for cancer at Ennis General Hospital involved serious medical errors, compounded by misdiagnosis, emphasises yet again the vulnerability of patients, the inadequacy of hospital information systems, and an ongoing lack of accountability. Her husband, Karl Henry, was courageous to go public on the circumstances of her case history yesterday. His recount of the medical handling of his wife’s interface with the medical system was compelling – if chilling.
There can be no such thing as a mistake-free medical service. Inadequate equipment and human error will always ensure that a small percentage of blunders are made. But this case went beyond all of that. It confirms the need to establish a limited number of centres of excellence, involving multi-disciplinary care teams.
Breast cancer services are no longer provided at Ennis hospital. Within the next few months, similar services are scheduled to be withdrawn from hospitals at Castlebar, Sligo, Tralee, Wexford, Kilkenny and Drogheda and transferred to nominated centres of excellence. Local people have protested against these changes. And they have been encouraged, in some instances, by medical professionals with vested interests. The Government and the Health Service Executive (HSE) must ensure, in these difficult financial times, that the necessary personnel and the funding for designated cancer care centres are made available.
Ms Moriarty was treated for breast cancer at St James’s Hospital in Dublin in 2005 and underwent a mastectomy, chemotherapy and radiotherapy. On her return for a check-up, in April 2007, she received a clean bill of health. Why then did the hospital carry out a mammogram, which is now missing? Two months later, at Ennis, a chest X-ray was misread as being normal by a locum consultant radiologist. In August, when she was obviously very unwell, doctors in the emergency department misread a second X-ray. And, blood test results were not acted upon. Following her death earlier this year, a request by her husband, Karl Henry, for an independent investigation into whether other cancer patients had been similarly misdiagnosed was turned down by the HSE.
The failures in this case arose from poor administrative and information systems, as well as from serious human error. The establishment of multi-disciplinary care teams will minimise the potential for human error. But as the Government Commission on Patient Safety and Quality Assurance advised last month, other structural and administrative shortcomings can only be addressed through legislative action. And given the difficulty involved in securing agreement with the various medical interests, Minister for Health Mary Harney will have her work cut out. A formal licensing system for all hospitals, medical centres, family doctors, and other care providers is needed. Chief executives and managers of services should be subjected to the same ethical and disciplinary system as healthcare professionals and should be accountable for patient safety.