The Lung Function Test
The results of a Lung Function Test completed in December, 2004, in Merlin Park Hospital, Galway, which were acknowledged, at various stages, to be either significant, abnormal or grossly abnormal were not seen by the patient's Consultant, in Mayo General Hospital, until 2 weeks later, 10 days after the patient had died. Even then, they were only seen due to a request from the patient's GP. This was an unacceptable delay. There was a serious deficiency in the administrative standards and procedures for reviewing incoming post in the typing pool.
The internal communication systems in Mayo General Hospital were inadequate in that the test results, although abnormal, were not seen by the Consultant or the patient's General Practitioner in a timely manner.
There is a conflict of evidence relating to the procedures in December 2004 for the receipt of incoming test results from the Pulmonary Function Laboratory in Merlin Park Hospital, Galway, to Dr Smith, Mayo General Hospital. On the one hand, the Hospital management and Dr Smith's public secretary have stated that incoming test results for Dr Smith's public patients were delivered to the typing pool where they were placed in his postal slot. On the other hand, Dr Smith, his personal secretary and the hospital postman have stated that any post addressed to Dr Smith was delivered to his private rooms, where it was checked daily. I have been unable to resolve this conflict of evidence. However, in the present case, it is established beyond doubt that the test results were, for whatever reason, deposited in the postal slot of Dr Smith in the typing pool.
The fact that such conflicting descriptions should present, about what should be a simple process of delivering and reviewing important patient related information, is totally unacceptable and highlights a system requiring urgent attention. In addition, in the interests of proper hospital governance, the matter of information relating to public patients being received by private staff of a hospital consultant, requires attention.
The policy of the Pulmonary Function Laboratory in Merlin Park Hospital, Galway, is to automatically send test results by ordinary post, unless the requesting physician stipulates an alternative method of delivery. This system needs to be reviewed in association with referring agencies to ensure best practice across the continuum of test completion, reporting, delivery and medical review.
The form which was used to request the Lung Function Test, (designed by University College Hospital, Galway) did not contain a provision for the inclusion of a telephone contact number or a fax contact number of the Doctor requesting the Test. This contributed to a further serious weakness in the general communication systems relating to test results in Mayo General Hospital.
Missing Manuscript Note
It was inappropriate for Dr Smith, following a request from the patient's GP for a copy of the test results, to omit an integral part of the results from the copy which was sent to the patient's GP. This note was an important part of the record; it was written to assist non-respiratory experts to understand the detailed numerical results. As such, its removal could reduce the meaning of the results for the patient's GP, a key person in Mrs Brown's care.
Implications for Health and Welfare of Patients
The system used for communicating results of tests employed in this instance, had serious risk implications for the health and welfare of patients.
In this particular case, independent, expert clinical advice made available to me has suggested that Mrs Brown's death was not caused by the administrative failings outlined elsewhere in this report. However, I consider that the administrative failings could create serious risk for other patients in the future and thus must be dealt with as a matter of urgency. In addition, the presence of such administrative failings caused a grieving family to question whether the sudden and traumatic death of their loved one could have been prevented if matters had been dealt with differently.
Hospital Information System
The patient died in an ambulance on her way to Mayo General Hospital. However, this death was not recorded on the Hospital's Information System at the time, or immediately afterwards. Subsequently, a post mortem was carried out in Mayo General Hospital, but again this was not recorded on the Hospital's Information System. This represents a serious weakness in the Hospital's records management systems. A formal complaint was also being examined about Mrs Brown's death by the hospital, and yet this did not prompt capture of Mrs Brown's death on the system either. This simple failure to record the patient's death, resulted in two insensitive letters issuing to the patient's family in the following 11 months, one with regard to an appointment for an endoscopy, the other with regard to renewal of a medical card.
Examination of the Brown family's complaint
There was an unacceptable delay by Dr Smith and the Hospital in dealing with the Brown family's concerns following the death of Mrs Brown. Mr Brown's daughter initially contacted Dr Smith's office in December 2004, and in the absence of a definitive response to this enquiry, Mr Brown wrote to Mayo General Hospital in April 2005. The Hospital issued a written response on 23 December 2005, more than one year after the family's initial complaint to Dr Smith and eight months after they had written to the Hospital.