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Misdiagnosis report recommendations must be implemented – Ó Caoláin

18 April, 2011 - by Caoimhghín Ó Caoláin TD


Sinn Féin Health spokesperson Caoimhghín Ó Caoláin TD has said that lessons must be learned and recommendations implemented from the report of the National Miscarriage Misdiagnosis Review.

He said:

“This report arises from the very traumatic experience of women who were misdiagnosed as having had a miscarriage. The report highlights where the system went wrong and makes recommendations for best practice in future.

“It is essential that the lessons of this Report are learned and its recommendations implemented. Its call for the upgrading of hospital equipment where necessary is a key recommendation and needs to be put into action as soon as possible by Health Minister James Reilly.

“It is disappointing that the Review did not have within its scope the role of the former Minister for Health & Children Mary Harney and her Department.

“The review was prompted by Melissa Redmond and other mothers who went public on this issue in June 2010.

“But when I put a Dáil Question to former Health Minister Harney at that time, she admitted in her Reply that she and her Department were made aware of Melissa Redmond’s case in August 2009. Measures were taken in response to the individual case but there seems to have been no attempt to assess if this had wider implications across the health system. We now know that the case was indeed symptomatic of a wider problem.”

ENDS

QUESTION NO: 274
DÁIL QUESTION addressed to the Minister for Health and Children (Ms. Harney (Dublin Mid-West) by Deputy Caoimhghín Ó Caoláin for WRITTEN ANSWER on 15/06/2010

* To ask the Minister for Health and Children when the misdiagnosis of miscarriage in the case of a person (details supplied) in County Dublin at Our Lady of Lourdes Hospital, Drogheda, County Louth and the resulting hospital internal inquiry was first brought to her attention; the action that she has taken; the further action she intends to take in view of this and similar cases; and if she will make a statement on the matter.

- Caoimhghín Ó Caoláin

Details Supplied: Melissa Redmond , Donabate, Co. Dublin.


REPLY.

I would first like to say that all incidents of this kind are serious and are treated as such. They are distressing to the women and families involved and I wish to again express my sincerest sympathies to all of those that are affected.

On 7 August 2009, the Solicitors for this person wrote to Our Lady of Lourdes Hospital, Drogheda seeking certain assurances about her care and other actions to be carried out by the hospital.

On the same day, the solicitors wrote a short letter to me enclosing a copy of that letter. This was also copied to the CEO of the HSE and to the State Claims Agency.

The case was handled by my Department in line with the Patient Safety Protocol which was adopted in September 2008. The protocol deals with correspondence from patients, doctors, health service staff and solicitors. It is managed by the Chief Medical Officer on my behalf as a medical assessment of any potential patient safety issue is required.

Both my Department and the hospital treated the letters with urgency. Within one week the HSE responded to the solicitors and a further letter was sent on 24 August. I was copied on both these letters.

In line with the Protocol, my Department followed up by telephone and by letter with the HSE to determine if there were risk issues arising from their investigation of the case. The HSE reviewed the case and confirmed that it had put a number of measures in place to ensure that the chances of making an error of this kind again are minimised.

The Chief Medical Officer was satisfied that the case had been dealt with appropriately by the HSE. At the time of completion by April last, it was assessed that the review and follow up actions for patient safety had been put in place at the hospital.

Measures put in place by the HSE in Our Lady of Lourdes Hospital, Drogheda, following this incident include:

A policy was put in place to ensure that no patient is prescribed a drug to take prior to a D&C (Dilation and Curettage) until the diagnosis of 'missed miscarriage' has been confirmed by a qualified sonographer through a second scan;

A “split” examination couch was put in place in the unit to facilitate the scanning procedure;

The scan machine that was in use in the hospital was replaced;

In July of this year a dedicated qualified sonographer will be assigned from 9.00 to 13.00;
The adjacent rooms/offices of the Gynaecological ward are used to speak privately with women and their partners.

A number of actions have been agreed by the HSE in conjunction with my Department to ensure the safe management of early pregnancy loss across the country.

The HSE is in the process of initiating a review of cases over the past five years to determine the number of patients who were recommended drug or surgical treatment when the diagnosis of miscarriage was made in error, and where subsequent information demonstrated that the pregnancy was viable. The terms for the conduct of the review are being finalised at present and will be made public very shortly. At that stage the HSE will be in a position to provide an indicative timeline for the completion of the review.

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