FITZGERALD REPORT:A REPORT has blamed "systemic weaknesses in governance, management and communication" within the HSE for the problems that arose during a review of breast cancer services at the Midland Regional Hospital in Portlaoise.
The report, by former Dublin City manager John Fitzgerald, does not name or blame any specific individual, but says systemic problems must be tackled to prevent any re-occurrence.
An inconsistency and lack of clarity in communications was the "inevitable result" of the deficiency in overall management of the review of patients' breast examinations, Mr Fitzgerald finds.
One of three reports on the affair published yesterday, Mr Fitzgerald's work covers the period from late August 2007, when the HSE suspended breast radiology service at Portlaoise, placed a consultant on administrative leave and started a clinical review of breast cancer services at the hospital, to the end of November, when clinics were set up to review ultrasounds.
During the review, 3,037 mammograms in respect of 2,150 patients, and 648 ultrasounds in respect of 607 patients, were reviewed. While the review of ultrasounds did not show up any misdiagnosis, the mammogram review revealed that nine women who had been given the all-clear actually had cancer.
Mr Fitzgerald says his report does not focus on individuals because to do so "would be unfair given the considerable pressure of work that people were under, but more importantly that by doing so I might create the erroneous impression that problems arose primarily from the action or inaction of individuals, rather than what in my view were systemic problems of governance, management and communications".
He says that at no time during his review did he identify any suggestion of "wilful neglect". However, from the outset, there was a "fundamental weakness" in the management and governance of the process due to a lack of authoritative co-ordination.
"The review facilitation group [set up in late August] did not work effectively. It met on three occasions and this does not reflect the kind of urgency and level of oversight that should have been accorded a matter of this importance." Attendance varied from meeting to meeting, Mr Fitzgerald also notes, and the group did not sign off on terms of reference.
"It did not exert control over the integrity of the communications process either with patients, with the Department of Health, or internally. It did not maintain sufficient oversight of the two elements of the process, mammography and ultrasound."
The report says a number of consequences flowed from this lack of overall management and co-ordination. Communication was inconsistent, confused and sometimes contradictory. The two processes of reviewing mammograms and ultrasounds became separated. Different people had different understandings of what was going on, and there was a lack of clarity about the terms of reference.
The confusion that arose at an Oireachtas health committee in November, when news of the ultrasound reviews first emerged, was "not surprising".
Mr Fitzgerald says he was particularly struck by the urgency and resources devoted to the fallout from these reviews, given these patients were in a much lower risk category, compared to what went before. "I cannot help but conclude that had the same level of urgency, attention and resourcing been available throughout, then many problems could have been avoided."
Too many people from different levels in the HSE were involved without clarity about their roles and responsibilities, he says. "The decision-making process was fragmented, with insufficient clarity about decisions, who was making them, why they were being made, or when they were signed off."
Key people were "distracted" by other important issues and there seemed to be an issue about prioritising. He is also critical of inconsistency and a lack of clarity in HSE press releases about the number of patients affected. "The 'drip feed' of numbers could only have heightened anxiety and uncertainty for those patients potentially affected."
All patients whose cases were being reviewed should have been written to. Media hysteria about the ultrasound review caused more concern for the women potentially affected, he concludes.
