Dáil Éireann Debate, Tuesday - 6 February 2018
362. Deputy James Browne asked the Minister for Health the status of the recently published external review of a case (details supplied) at Wexford General Hospital; and if he will make a statement on the matter. [5512/18]
Amharc ar fhreagra363. Deputy James Browne asked the Minister for Health the reason concerns expressed by a person employed by the HSE regarding clinician Y were not referred to in the internal HSE review of cancer screening at Wexford General Hospital; and if he will make a statement on the matter. [5513/18]
Amharc ar fhreagra364. Deputy James Browne asked the Minister for Health the steps he will take to ensure that the delays arising from complaints regarding professional standards at hospitals are kept to a minimum in view of external review of bowel cancer screening at Wexford General Hospital; and if he will make a statement on the matter. [5514/18]
Amharc ar fhreagra365. Deputy James Browne asked the Minister for Health the status of the implementation of recommendations outlined in the recently published external review of a case (details supplied) at Wexford General Hospital; and if he will make a statement on the matter. [5515/18]
Amharc ar fhreagra366. Deputy James Browne asked the Minister for Health the reason the HSE did not maintain open disclosure as promised to families affected by probable missed cancers at Wexford General Hospital during the completion of the external review of a case (details supplied); the reason the HSE did not inform the families affected of the concerns expressed by a person concerning clinician Y; and if he will make a statement on the matter. [5516/18]
Amharc ar fhreagraI propose to take Questions Nos. 362 to 366, inclusive, together.
On 24 January 2018, the HSE published the report of the External Review of the overall management of an incident involving probable missed cancers at Wexford General Hospital that arose in carrying out colonoscopies under contract to the BowelScreen programme in 2013/2014.
The External Review was undertaken, following on from the publication of the Serious Incident Management Team (SIMT) report in January 2017, to assess the governance and management of the look back process and to examine the current governance arrangements between BowelScreen and those hospitals providing services for BowelScreen. It was carried out by Professor Robert JC Steele of the University of Dundee.
The External Review concluded that the look back process was carried out in a timely and efficient manner. It noted that, while there were missed early opportunities to identify shortcomings in the performance of the colonoscopist involved, there were significant mitigating circumstances surrounding this. The review also noted that current quality assurance governance arrangements between BowelScreen and its provider units are appropriate.
The HSE advise that patients received open disclosure at the time of diagnosis and that open communication was maintained thereafter. Patients and their families were made aware of the commissioning of the External Review and were notified of the findings of the review in advance of its publication.
The outcome of this review, and the earlier SIMT report, is that more robust procedures are now in place for the benefit of patients. To date BowelScreen has:
- Implemented a new policy to manage safety incidents, so that serious issues are managed in a standardised and appropriate manner;
- Developed enhanced policies and procedures to strengthen early warning systems and to ensure that a proactive response is taken;
- Revised the relevant agreements with hospital partners to include all relevant quality assurance guidelines;
- Augmented and clarified the requirement for detailed clinical audit at local level;
- Increased the minimum Adenoma Detection Rate (this is the standard measurement of clinical quality in endoscopy) from 25% to 45% and commenced measurement at individual clinician level;
- Completed the revision of Programme Quality Assurance Guidelines; and
- Put in place arrangements to commence reporting on interval cancers once the data is available.
Meanwhile, the HSE launched its revised Incident Management Framework on 24th January 2018. The Framework incorporates guidance on making decisions about appropriate pathways for investigation and review, including in situations where staff may have concerns in relation to the performance of a colleague.
