Interviews

Introduction

As mentioned earlier, for the purposes of my Report, the complainant's name and that of his late wife have been changed to protect their identities. The names of the staff of the HSE, and others, have also been changed.

As part of the investigation, my staff interviewed the following individuals;

• Mr Brown, the complainant,
• Dr Greene, Consultant in Respiratory Medicine, Merlin Park Hospital, Galway,
• Dr Murphy, former Research Registrar, Merlin Park Hospital, Galway,
• Mrs Kelly, Senior Technician, Lung Function Test Unit, Merlin Park Hospital, Galway,
• Ms Byrne, Clerical Officer, Secretary to Dr Smith, Consultant Physician and Gastroenterologist, Mayo General Hospital, Castlebar
• Ms Butler, Clerical Officer, Secretary to Dr Mallen, Consultant, Mayo General Hospital, Castlebar,
• Dr Smith, Consultant Physician and Gastroenterologist, Mayo General Hospital, Castlebar.
• Dr Charles, Locum Consultant Physician, Mayo General Hospital, Castlebar
• Dr Doyle, Mrs Brown's General Practitioner.
• Mrs Moore, Personal Secretary to Dr Smith
• Mr Martin, Postman, Mayo General Hospital, Castlebar

Mr Brown, Complainant

My investigator met with Mr Brown at his home. He explained that following the visit of he and his wife to Merlin Park Hospital, Galway in December 2004, he and his wife returned home. He said that his wife was in good spirits for a few days. She did her usual housework. She visited the town of Knock on Saturday to do some shopping. She bought some clothes and some holly for Christmas. She also took a bus to Swinford on her own. Neither had any idea about the serious state of her health. They simply carried on with their daily routine, as normal.

Mr Brown said that his wife went to bed early 4 nights later. It was about 8.15 pm - she had been doing this for the previous few weeks as she was tired. At about 8.50 pm she came running up the corridor and told her husband that she was feeling unwell. She said she needed oxygen. She was on her hands and knees and screaming.

Mr Brown rang Westdoc, which is the local out-of-hours GP service in the area. He was asked to bring her in, but he explained that he couldn't do this, as his wife was too distressed. The doctors came out to the house and put Mrs Brown on oxygen straight away.  The ambulance came and the paramedics gave her an injection to calm her down. They carried her out on a stretcher to the ambulance.

At this stage Mr Brown still didn't think his wife was in any danger.  He followed the ambulance out the road to Castlebar. However, after a while, the ambulance stopped in the middle of the road and he saw the paramedics performing Cardiopulmonary Resuscitation (CPR) on his wife. Mr Brown said that his wife passed away in the ambulance at about 11 pm. Her body was taken to Mayo General Hospital, where a post mortem was later carried out.

Mr Brown said that he and his daughters were totally misled about his wife's state of health. He said that neither he nor his wife were advised that she was seriously ill. He said that it seemed to him that the Clinic in Merlin Park Hospital, Galway, simply let her walk out of its offices on 1 December 2004 in the full knowledge that her medical circumstances were very grave. He said that the seriousness of her condition was obvious from her physical state and the test results.

He said that he could not understand why nobody told them that his wife was seriously ill. He added that, when the test results were available, they were noted as abnormal, but they were simply put in the ordinary post and sent to Dr Smith, who never saw them, until it was too late.

Mr Brown felt there should have been some procedure or  "red alert" way of notifying the doctors of his wife's condition, given the results of the Lung Function Test.  He said that he was not advised when his Doctor would be told about the Lung Function Test results. However, given the results which were found, he said that he would have expected that the family Doctor would have been told immediately.  He would have expected, based on his wife's abnormal test results, that the Hospital would have used a "Hot line" to alert the Doctors who were looking after her.

He felt that simply relying on the post is not the way to deal with a person's life. Mr Brown told me that he had trusted the medical people too much and he, his family and his wife, were let down.

Dr Greene, Consultant in Respiratory Medicine, Merlin Park Hospital, Galway

Dr Greene is the Consultant in Respiratory Medicine in Merlin Park Hospital, Galway with responsibility for the Pulmonary Function Laboratory. He did not see Mrs Brown. He explained that the late Mrs Brown visited the respiratory service in December 2004, some 4 days before her untimely death. He said that the locum Consultant's Registrar requested Pulmonary Function Testing in November 2004. The patient was given an appointment and duly attended.  The tests were conducted by Mrs Kelly, Senior Respiratory Technician. He acknowledged that the test results were abnormal. Mrs Kelly had brought them to the attention of Dr Murphy, his Registrar.  Dr Murphy wrote his comments on the Test Result report which Mrs Kelly dispatched by post to Dr Smith in Mayo General Hospital on the same day.

Dr Greene said that he was reluctant to comment on the "significance" of the abnormal results without possession of the other relevant clinical information, as his comments could be misconstrued or taken out of context. He pointed out that, as with all diagnostic testing, the more clinical background provided, the more appropriate and relevant is the subsequent interpretative report. Dr Greene explained that tests of lung function must be reviewed in the context of a

• patient's history,
• physical examination and
• other test results.

The Lung Function Test results are interpreted by Dr Greene or the Specialist Registrar in Respiratory Medicine and the final report then sent, by post, by the technical staff to the referring Consultant, as given on the request card.

Dr Greene explained that Lung Function Testing (see Appendix 1) assesses three main aspects of pulmonary function, namely:

• airway function,
• lung elasticity and
• gas exchange.

He said that the late Mrs Brown presented with a condition of breathlessness of un-stated duration. The request card mentioned

• a normal chest x-ray and
• a history of Raynaud's disease

He explained that the Lung Function Test results obtained in Mrs Brown's case, showed no evidence of an airway abnormality. The lung volumes were reduced.  According to Dr Greene, the test results represented a restrictive defect, with severely impaired gas exchange. He said that he would expect a patient with such values to be breathless on exertion and there were indications of a primary lung abnormality being the cause of her breathlessness.

Dr Greene explained that Lung Function testing is an addition or complement to a diagnosis and treatment. The results must be correlated with the patient's history, clinical signs, radiology and other results.

He stressed that the referring clinician is best placed to offer an explanation to the patient on the test results. He pointed out that Lung Function Testing is not a "stand alone" entity and should not be viewed out of context (whether normal or abnormal values are obtained) and that the Lung Function Tests must be seen in the light of the clinical circumstances and other abnormal test results.

Dr Greene explained that the condition of patients with Mrs Brown's level of lung function would be very serious if it had developed over a short interval i.e. days rather than months. In Mrs Brown's case, the condition had evolved over the previous months.  He clarified that, in lung disease, there is often a threshold effect i.e. the patient shows virtually no symptoms until 30-40% of the lung function has disappeared.  He said that, while reflecting significant abnormality, he would not have predicted the subsequent outcome in Mrs Brown's case. He pointed out that her rate of decline certainly was unexpected. 

In this regard, he emphasised that Mrs Brown walked in and walked out of the Pulmonary Function Laboratory and performed the tests without difficulty.

Internal Laboratory Procedures

Dr Greene reviewed the Laboratory's internal procedures in detail with his technical staff.  He highlighted the following points:

• The present system evolved through ongoing reflection and review over the past 18 years while he has been there. Like other diagnostic laboratories in UCH and Merlin Park Hospital, the test result report is issued only to the referring clinician. No reports are given to the patient or sent to the GP.
• As with other diagnostic tests, the onus remains with the requester to have a robust system in place for the receipt and integration of normal and abnormal results.
• The Laboratory in Galway has a "tracking system" in place to monitor reports which are not received by the requesting party.                    
• The Laboratory in Galway, as part of its quality assurance programme, is now issuing reports on all test results.
• The Laboratory now stores a backup copy of the test graph numbers and the interpretative report.

In a report prepared by Dr Greene on the case and made available to my staff during his interview, he commented on a suggestion which had been made, that the Lung Function Test report should have been conveyed differently to Dr Smith. In this regard, he stated that

• It is unlikely that the abnormal lung function testing was the pivotal finding in this case.
• To relay abnormal reports, other than by paper, would impose a workload on the laboratory which would seriously hinder its capacity to deliver the present level of service.
• Currently the laboratory undertakes 5,500 procedures per year, of which at least 30% are abnormal.
• To the best of his knowledge, no equivalent laboratory in any of the Dublin teaching hospitals report except by paper - post.
• The laboratory will, of course, fax results if requested.

When probed whether Mayo General Hospital should have been alerted by phone or fax to bring these particular test results to the attention of Dr Smith or his team at an early date, particularly given the specific test results and Dr Murphy's manuscript note, Dr Greene clarified that test results are normally sent by post. He confirmed that they would be faxed back to the requester if the Laboratory was asked to do so. He pointed out that the results themselves do not determine the method of delivery to the requesting Consultant. However, he suggested that, given the issues presenting in this case, the HSE could do a Risk Assessment to determine how the Pulmonary Function Test Laboratory procedures are carried out and possibly come up with some improved procedures. In saying this, he said that Mrs Brown's Test Results did not fall into the emergency situation which would dictate urgent action.

Dr Murphy, former Research Registrar, Merlin Park Hospital, Galway (2003 to 2005)

Dr Murphy was the Research Registrar in Merlin Park Hospital, Galway, in the period 2003 to 2005.

Dr Murphy explained that the main task in the Pulmonary Function Test Unit was to conduct Lung Function tests, produce test results, and convey the results, with a commentary, to the patient's referring medical Consultant. He confirmed that the standard method of conveying results was by ordinary post.

He concurred with Dr Greene's view that, in Mrs Brown's case, the test results were significant in terms of her lung function. However, he clarified that he did not see the patient. In addition, he stated that one could not determine the patient's condition, simply by reference to the results of her Lung Function Test. He explained that there are different variables at play and any prognosis would be dependent on the patient's medical history and the nature of her illness. He pointed out that it is a matter for the patient's primary referring Consultant to determine the urgency of conducting the test and the urgency of receiving the test results.

Dr Murphy said that it is the normal practice to send test results by ordinary post . He explained that, if the patient was in good shape and stable enough when leaving the clinic after the test, which can be arduous enough, then sending the test results by post would be sufficient. However, he clarified that, if a patient deteriorated during the test, then the Laboratory would call ahead to the referring Consultant and alert him/her of the patient's condition

He said that it was not the  normal practice to ring ahead or fax the results to the referring Consultant, unless the Laboratory received a specific request from the referring Consultant, who, he said, would be best placed to know the patient's medical history.

Mrs Kelly, Senior Technician, Lung Function Test Unit, Merlin Park Hospital, Galway

Mrs Kelly has been a nurse in Galway for 30 years. She moved to Merlin Park, to a full time position in the Pulmonary Function Laboratory and has worked in this area for 18 years.

Mrs Kelly had no knowledge of  the assessment which was carried out in Mayo General Hospital in November 2004, in the Medical Assessment Unit. Mrs Kelly explained that the referral form which she received, when the appointment was being requested, showed the consultant's name and the patient's name, date of birth, illnesses and symptoms.

Mrs Kelly carried out a Lung Function Test on Mrs Brown in December 2004, between 12.00 and 13.00. She recalls that the test probably took about 30 minutes. She said that Mrs Brown walked in to the Laboratory. She had been driven to Galway by her husband and he remained in the car park. Mrs Kelly

• took the patient's coat,
• asked her to remove her shoes and
• measured her weight and height.

She explained the details of the tests to the patient and advised her that, sometimes it might be necessary to take up to 10 tests to get the correct readings. She recalled that Mrs Brown was a petite woman, who was very quiet, but she did not appear to be breathless. She had Raynaud's Disease.

Mrs Kelly explained that her responsibility was mainly the patient's safety, to ensure the machines are calibrated correctly and that the results are correct. She said that once the test was carried out, the results were available immediately. The results were printed off for Dr Murphy's attention.

She noted that the results for the Spirometry were not too bad. However, she saw that the Diffusion test result was very poor. In fact, in her view, the Diffusion test results were grossly abnormal (see Appendix 1 for information on Spirometry and Diffusion). 

She added however that it was very hard to tell exactly how abnormal the test results were. She explained that one would really have to have known the patient's history. One would need to know whether the patient was on a plateau, or whether she had deteriorated to this state rapidly. She explained that the worst situation would have been if there was a rapid deterioration. However, Mrs Kelly was not in a position to say how bad the patient's condition was, as she did not know Mrs Brown's medical history.

She showed the test results to Dr Murphy.  He added a hand-written note to the results sheet and gave it back to her. She posted the document immediately to Dr Smith in Mayo General Hospital. The manuscript note stated as follows:

"Significant decrease in DLCO consistent with restrictive lung disease. Compare with Haemoglobin and patient's x ray chest."

Mrs Kelly confirmed that the manuscript note was on the copy of the test results which were sent to Mayo General Hospital.

When asked whether, in her view, the test results were 'time sensitive' from the patient's perspective, Mrs Kelly agreed that she felt they were time sensitive and that this was the reason they were posted on to Dr Smith immediately. 

Mrs Kelly said that she did not give any feedback to the patient. Mrs Brown did not ask any questions either. Furthermore, she did not give any instruction to Mrs Brown as to what she should do next. Mrs Brown would simply have been told that the Laboratory would send her test results to Dr Smith, her Consultant Physician in Mayo General Hospital.

Mrs Kelly pointed out that the Lung Function test results are only an adjunct to a diagnosis. She explained that one cannot make a diagnosis on the basis of Lung Function test results alone.

Having regard to the contents of the test results and the manuscript note, I enquired whether Mayo General Hospital should have been alerted by phone or fax that these results should be brought to the attention of Dr Smith, or his team, at an early date. In response, Mrs Kelly confirmed that the test results were not faxed, nor did she ring ahead advising Mayo General Hospital that she felt the test results were abnormal.

She explained that she has no clerical staff and that she was the only person in the office at the time. She said that, due to her workload, she simply had no time to go looking for a phone number or to try to find out who Dr Smith was, or where his offices were located. She pointed out that the Pulmonary Function Test Laboratory receives hundreds of requests for test results. However, if a fax number had been supplied, she confirmed that she would have replied by  fax.

She also pointed out that, if she had been told that the results were needed urgently, she would have faxed or telephoned to let Mayo General Hospital know the test results were on the way. She stressed that she had not received such a request. She also confirmed that it was not her role to determine which test results are urgent or not.

When asked about the usual procedure for alerting a patient's consultant, in cases where the test results show abnormal readings, Mrs Kelly explained that

• tests are requested by the referring Consultant,
• tests are completed,
• the results are printed,
• the Respiratory Consultant sees the test results and usually
• writes a report on the Results sheet and
• these are then posted to Mayo General Hospital in Castlebar.

When asked about who is responsible for deciding on the form of transmission of test results to the patient's Consultant, e.g. by fax, email or phone alert, she explained that she presumed it was Dr Greene's responsibility, as Head of the Department, in urgent cases. She confirmed that, ordinarily, the technicians would post the test results to their destination.

Mrs Kelly repeated that she was responsible for posting the test results in this instance. They could have been faxed, but no fax number had been given to the Laboratory.  In any event, she would not have the time to seek out a fax number for the Consultant involved. She had no clerical staff to do this and the Laboratory is extremely busy.

In conclusion, Mrs Kelly indicated that she would probably ring ahead if she was faced with a similar situation in the future, provided she had been given a contact number by the requester.

Ms Byrne, Clerical Officer, Secretary to Dr Smith, Consultant Physician and Gastroenterologist, Mayo General Hospital, Castlebar

Ms Byrne started work at the Hospital in April 2002. She is a Clerical Officer and has been working in the Hospital's typing pool for 4.5 years. She trained in Filing Records before she was appointed as Secretary to Consultants O'Sullivan and Smith. She said that she does all the public work for Dr Smith.

Ms Byrne outlined the standard procedure in respect of the receipt of test results. She said that test results come in an envelope marked for the attention of a particular Consultant. They are placed in the Consultant's postal slot, which is located in the typing pool room on the ground floor, where they could be easily accessed. Each Consultant has a designated postal slot and, given the layout, it is visually obvious when post is backing up, or a large amount of post is awaiting the attention of a specific Consultant.

Ms Byrne said that it was not unusual for her to ring Dr Smith to tell him there was post waiting for him in his postal slot in the typing pool room. She said that she was pro-active in alerting him to the fact that post had been received for him.

I enquired as to whether the test results for public patients were processed in the same manner as those for private patients. In response, Ms Byrne explained that private patients are dealt with in Dr Smith's private clinic in Castlebar and all his post for his private patients goes to his private secretary and his private rooms.

I asked Ms Byrne if she had requested that the Pulmonary Function Laboratory in Galway alert her of the results in this case, immediately they came to hand. In reply, she explained that the Consultant is responsible for issuing all such instructions, including urgent cases. She confirmed that any urgent cases are referred back to the Hospital by fax. She also confirmed that, if the Consultant was not around, she would ring him to let him know that any predetermined urgent results had been received.

Ms Byrne confirmed that she would not be in a position to notice whether a test result was abnormal, or if a special note was added to it by a Consultant in Galway. She pointed out that it is not her place to study every report that comes in. In addition, as a Clerical Officer, she is not in a position to diagnose or interpret reports. Indeed she has no training in this regard and she would not have the authority to consider what was irregular or unusual.

When I enquired why Dr Smith only saw the test results some time after they were posted from the Laboratory, Ms Byrne advised me that this was explained by the fact that he didn't always come down to check his post and look for them. She explained that her practice was to ring consultants to advise them when post was in their postal slots awaiting their attention.

When asked whether Ms Byrne had a role in ensuring that test results do not linger in the Consultant's postal slot for any length of time, she explained that she can only ring a Consultant and advise him of the arrival of post.

Ms Byrne said that there was no way of establishing when Mrs Brown's test results were actually received in Mayo General Hospital, as they were not date-stamped on arrival. She confirmed that there is always a manuscript note on the test results which are received in Mayo General Hospital from the Pulmonary Function Laboratory in Galway. However, as she was on annual leave on the day the complainant's GP, Dr Doyle, rang making enquiries about Mrs Brown's Test Results, she did not actually see them on that day.

Ms Butler, Clerical Officer, Secretary to Dr Mallen, Consultant, Mayo General Hospital

Ms Butler was standing in for Ms Byrne as Dr Smith's Secretary in December 2004, the day Dr Doyle, Mrs Brown's GP, rang the Hospital seeking the test results for Mrs Brown. She is a Clerical Officer and Medical Secretary to Dr Mallen, Respiratory Consultant.  She has held this position for 6 years.

She explained that a call came through from Dr Doyle. He told her that the patient had died four days earlier and he asked her about the LFT results. She found the Lung Function Test Results in the Typing Pool. She advised Dr Smith about the enquiry from Dr Doyle, Mrs Brown's death and showed him the LFT report.  She advised Dr Smith that Dr Doyle had requested a copy of the LFT report and she asked Dr Smith if she could send it to Dr Doyle.

Ms Butler told me that Dr Smith told her to photocopy the report and to send it to Dr Doyle by fax, but not to include the manuscript note from Dr Murphy, which appeared at the bottom of the results sheet. On receiving this instruction, Ms Butler photocopied the report, with the manuscript part folded over, and then, once she got a copy of it, she faxed the copy, without the manuscript note, to Dr Doyle's Secretary.

Dr Smith, Consultant Physician and Gastroenterologist, Mayo General Hospital, Castlebar

Dr Smith said that he has worked in Castlebar General Hospital since 1993. He is a Consultant Physician and Gastroenterlogist. He has an average caseload of about 130 patients. He has about 30/40 in-patients and 50/60 out-patients. He discharges about 5 patients per day and admits 5 patients per day. About 10% to 12% of his patients are private patients, while the balance are public patients.

Dr Smith explained that he had never actually met Mrs Brown. He said that she was referred to the Medical Assessment Unit, in Mayo General Hospital. She was seen in November 2004, by Medical Registrar, Dr McKeon (he was the Registrar for Dr Smith's Locum Consultant, Dr Charles), who arranged an appointment for the Lung Function Test in Merlin Park Hospital, Galway. Dr McKeon also arranged for a Cardiac Test to be undertaken. The date scheduled for the Lung Function Test was arbitrary in the sense that it was a routine test and the date was set to tie in with the Merlin Park Hospital's schedule. The appointment made by the Cardiac Department was for December 2004. Dr McKeon scheduled a follow-up appointment in December 2004, four weeks after the first consultation, in the Medical Assessment Unit in Mayo General Hospital.

Dr Smith explained that there was no arrangement in place to date-stamp test results when they came in to the hospital. The only time they might be dated is when the Clinician

• reviews the results,
• acts upon them and
• signs off on them.

However, in July 2007, Dr Smith said that he directed his secretary to note the date of receipt on the envelope of all Lung Function Test results.

Dr Smith said that it was clear that Mrs Brown's particular test results came in to the typing pool room. He added that there could be hundreds of post items coming in every day in the general post.

He said that the test results may have been addressed to him, or they may have come in the general post. He explained that when a batch of posted items arrives, it is sorted by staff in the typing pool room and each item is put into the individual Consultant's postal slot in the designated area.

In commenting on an extract of the draft investigation report, Dr Smith said that it has always been his experience that there is a delay in the receipt of reports etc., particularly Lung Function Tests. He explained that there is often a time delay with this process. He mentioned that some blood test results from a weekly Medical Clinic, may not arrive in the relevant doctor's postal slot for two or three days after that Clinic. He drew my attention to  his analysis of the exact time of arrival of Lung Function Tests since August 2007. This analysis indicates that test results arrive in his post 5 to 21 days after the tests have been carried out. He made the point that it has always been his impression that there are delays in the HSE internal post.

Dr Smith clarified that he would normally visit the typing pool to collect his post. However, the frequency of his visits would depend on how busy he was in his Clinic. He said that depending on circumstances, either he, or his Registrar, would call to the typing pool room two or three times per week. However, he acknowledged that on occasion it could be up to a week before he might review his post.

Dr Smith acknowledged that his secretary, in the typing pool, Ms Byrne would remind him if material for his attention was in his postal slot over an extended period. However, he admitted that he doesn't find the typing pool system very satisfactory and that he has brought this to the attention of management in the past. He explained that he has a private office in which he handles his private patients' work and some public patients' affairs, academic affairs and other office administrative duties. This private office is also used for interviews with staff and occasionally with patients.

In contrast, he explained that there are 12 secretaries serving 14 Consultants and about 46 Non Consultant Hospital Doctors (NCHDs) in the typing pool.

In commenting on an extract of the draft investigation report he described the typing pool as a confined space. He said that the only space available to the doctors in this room for doing paperwork is a nine inch by twelve foot ledge. He pointed out that there is no table for doctors and no central dictating facilities in this room. In addition, given its size, layout and number of occupants, he said there are continuous conversations going on in the room and accordingly there is no privacy.  He said that, having regard to this, he finds it very difficult to concentrate and conduct business from the typing pool. Finally, he made the point that most consultants and their teams in the hospital do not use the typing pool for receipt of their post and administrative / secretarial activities. He explained that these activities are carried out in their offices or in a departmental office.

He said that he would become aware of abnormal test results in his postal slot simply by going through his post. He explained that in urgent cases, he would expect some type of flagging on the report when it arrives. In saying this, he stated that he was not convinced that the staff in the Pulmonary Function Laboratory in Galway could have known that Mrs Brown would die in 3/4 days.

Dr Smith confirmed that the first thing he knew about Mrs Brown's abnormal test results was when he got a call, via his Secretary, that Dr Doyle, Mrs Brown's GP, was making enquiries.  He acknowledged that the test results might have gone unnoticed for a longer period, had he not received the phone call from Dr Doyle.

At a later stage in the investigation, when commenting on an extract of the draft investigation report, Dr Smith discussed with my Office how reports which are not specifically addressed to him would be sent to the typing pool, but reports and letters with his name on them would go to his personal office. This was relevant to the investigation, as he checks his post daily in his personal office, whereas he may not do so daily in the typing pool.

In light of these assertions, and in view of their conflict with evidence from other hospital sources, I again contacted the General Manager, Mayo General Hospital, and was told again that, at the time of the events in question, all post items, except those marked for Dr Smith's private office, were sent to the typing pool.

Given these different accounts, in an effort to seek further clarification on the matter, my staff interviewed Dr Smith's personal secretary and the hospital postman. An account of these interviews is provided later in this report. Notwithstanding these additional enquiries, I have been unable to date, to establish the definitive situation in relation to the issue of where test results addressed to Dr Smith are actually delivered and therefore reviewed.

Dr Smith described the test results as abnormal. However, he pointed out that there was no notion of the patient's immediate demise.  He confirmed that there was no way his secretarial staff would have known that the test results, as reported, were abnormal. He accepted that only he himself or his Registrar would have known this.

In commenting on an extract of the draft investigation report, Dr Smith pointed out that approximately 15% of all results received are abnormal. He clarified that many laboratories use indicators on their reports, so that abnormalities are easily detected. He explained that, for instance, abnormalities may be printed in red or may have an asterisk beside the abnormal finding. He explained that, with this type of report, it is possible for non-clinical people to discriminate between reports.

Dr Smith accepted that he arranged for Mrs Brown's test results to be faxed to Dr Doyle, her GP, immediately, but with Dr Murphy's manuscript note deleted from the copy which was sent to Dr Doyle.  He acknowledged that the manuscript note from Dr Murphy was an integral part of the overall report, but he was unable to recall why he had decided not to include the manuscript note from Dr Murphy, with the report.  He said that he did not speak to Dr Doyle about the test results.

Dr Smith explained that, if he had seen the test results within a day or two of the test he would have checked out the patient's medical notes and would have noted that she was scheduled to have an appointment at the Out-Patients Department in two weeks time. In addition, he said that there was nothing in the report to suggest that the patient would have died within three days of the test.

He acknowledged that there was a fault in the system, and there was a delay in looking at the test results. However, he pointed out that he saw the test results two weeks after the LFT was carried out and that the patient was scheduled for an appointment in the Medical Assessment Unit in a few days later, i.e. four weeks from her earlier appointment in the Medical Assessment Unit. He said that the patient had been referred by her GP, to whom she had relatively easy access. Accordingly, he was reasonably satisfied that Mrs Brown was being monitored on a month by month basis which, in his view, was the appropriate timescale for monitoring a patient with Mrs Brown's medical history.

Dr Smith stressed that if someone sees a report on a person which might suggest that the patient might be dead in three days, then this should be acted upon immediately. However, in this particular instance, he repeated that these results were not such a report and did not suggest an imminent death. The receipt and analysis of the report, had it been assessed before the patient died, would not have changed the arrangements for a follow up appointment, which was scheduled for 4 weeks after her first attendance. Dr Smith felt that this was the back-up system in place in this instance.

He was concerned that Mrs Brown's family would think that her death resulted from the fact that the LFT report was not seen and acted upon, immediately the results became known. He did not share this view.

Dr Smith was asked why an appointment was sent to the late Mrs Brown for a Gastroscopy Test, after Mrs Brown's daughter had been in regular contact with him and his clinic following the death of her mother.  The daughter had called during Christmas Week, on 8 January and in mid February 2005.  Given the frequent contact with his Clinic, Dr Smith was asked to explain why an  appointment letter was sent  4 months after Mrs Brown's death.

In reply, Dr Smith acknowledged that this was a very unfortunate occurrence and that it is the only instance where he can remember personally reviewing a deceased patient's notes and for this error to occur.  He said that his office can be very busy and sometimes mistakes can happen. He admitted that his staff were preoccupied with other things and this got overlooked. He acknowledged that this type of error is unacceptable and he told my Office that he was sorry for his error in this instance. In saying this, he confirmed that it is a common enough happening for appointments to be sent to a deceased person.

Dr Charles, Locum Consultant, Mayo General Hospital

Dr Charles explained that he did not actually see Mrs Brown when she called to Mayo General Hospital in November 2004, but that she was seen by the Medical Registrar, Dr McKeon.

However, Dr Charles examined the patient's file and confirmed that she had a number of tests carried out that day and, from an examination of the test results, he was satisfied that there was no significant indication that there was anything of significance showing up for the patient.

He pointed out that her Radiology report confirmed that the "Cardiac size and contour is normal" and that Mrs Brown's lungs were "over-inflated with increased markings in both bases, suggestive of COAD*". However, he stressed that the Radiology report stated that there was "no active lung disease identified."

* COAD: Chronic Obstructive Airway Disease.

Dr Doyle, Mrs Brown's General Practitioner

Dr Doyle said that Mrs Brown had been a patient of his for about 5 years. He explained that she suffered from a severe form of Raynaud's Disease and it affected her fingers and toes. Dr Doyle explained that Mrs Brown was in a lot of pain and her main reason for coming to his practice was to get some pain relief. He explained that she was on antibiotics and was also attending the Pain Clinic in Galway.

He pointed out that, in his letter of referral of 15 November 2004, to Mayo General Hospital, he sought Dr Smith's opinion on her condition. [In commenting on an extract of the draft investigation report Dr Smith clarified that Dr Doyle referred Mrs Brown to the Medical Assessment Unit (MAU) with a letter to an unspecified doctor. He explained that this is usual procedure for general referrals to the MAU.]  Dr Doyle pointed out that Mrs Brown was complaining of dyspnoea (Dyspnoea: shortness of breath) on exertion for the previous three weeks, with reduced exercise tolerance of approx. 200 yards. He mentioned that Mrs Brown also complained of weight loss of one stone over the previous four months. He clarified that there was a history of Raynaud's Disease affecting her fingers, causing her severe pain, for which she took very regular analgesia. Finally, he documented that her physical examination showed no obvious issues and her blood tests were normal.

Dr Doyle said that the purpose of the referral to Mayo General Hospital in November 2004, was to try to get a diagnosis for her illness, which was provisionally thought by the Hospital to be Schleroderma (Schleroderma: A systemic disorder of connective tissues with skin hardening and thickening, blood vessel abnormalities, and fibrotic degenerative changes in various body organs) - Systemic sclerosis, and to allow him chart a plan of action for her future treatment. He confirmed that his referral was primarily based on her recent weight loss and her shortness of breath.

When my officials drew Dr Doyle's attention to the fact that Mrs Brown was due to be reviewed in Mayo General Hospital in December 2004, i.e. within one month of her initial examination, he confirmed that, in his experience, this would be normal practice. This, he explained, was on the basis that all test results would normally be back after a four-week period.

Dr Doyle explained that, a few days after Mrs Brown's death, he drove from his home in County Mayo to the Pulmonary Function Clinic in Galway, on his day off, to get a copy of the LFT Results from Dr Murphy and he discussed these with him.  He said that the reason he drove to the Clinic in Galway was that, at the time, he felt there may have been a delay in getting the test results from Mayo General Hospital in Castlebar. In this regard, Dr Doyle pointed out that his medical practice has the facility to get test results electronically and he confirmed that he gets all his patients' blood test results electronically.

Finally, when asked why he had contacted Dr Smith's office in December, 10 days after the patient's death and requested Dr Smith's secretary to fax him the results, he said he could not recall this event.

Mrs Moore, Personal Secretary to Dr Smith, Consultant Physician and Gastroenterologist, Mayo General Hospital, Castlebar

Mrs Moore started work as Dr Smith's personal secretary on 22 January 2002. Prior to that she worked in England for 12 years. Her office is in Mayo General Hospital. Dr Smith has private rooms in the town, where he sees his private patients on Mondays. Mrs Moore works out of the private rooms on Mondays, when Dr Smith is seeing his private patients.

Her main job with Dr Smith is to look after his private patients. She also handles a lot of his correspondence in relation to other duties, for example, his academic work and organising presentations to other consultant teams . A lot of her time is spent on patient-related activities, as given Dr Smith's area of expertise, Gastroenterology,  his patients need to be seen straight away. She deals with Dr Smith's private patients only. She does not deal with the private patients of any other consultant.

In relation to post items, Mrs Moore explained that any post for Dr Smith, with his name on the envelope, comes to her, whether marked private or not. She said that she opens all his post, except that marked as "private and confidential". She does not date-stamp the post when it arrives.

She explained that, originally, when she took up duty in January 2002, Dr Smith opened his own post. At that time, his post, along with the post for other consultants, went to the Consultants' Rest Room. Dr Smith's post was collected by him from the Consultants' Rest Room. After about 2 or 3 months i.e. March / April 2002, Mrs Moore started to open Dr Smith's post and an arrangement was introduced that Dr Smith's post i.e. those envelopes with Dr Smith's name on it, was directed straight to Mrs Moore. (The arrangement for delivering post to the Consultant's Rest Room was terminated shortly afterwards and the post was routed through the Typing Pool.)

When asked to explain how the Lung Function Test for Mrs Brown ended up in the postal slot in the typing pool, she said that she could not explain how that happened. She emphasised that nearly 100% of post with Dr Smith's name on it, would come to her.

When asked to clarify what items of post are placed in the postal slot in the typing pool. Mrs Moore explained that any charts that Dr Smith would ask for and any letters which his public secretary would type up for him, are placed there for later collection by Dr Smith or his Registrar.

She explained that all Lung Function Test reports would be sent to her office, as they are marked for Dr Smith's attention. This was the case for both private and public patients. She clarified that she would have no reason or cause to visit the typing pool at any stage. She pointed out that, when she goes on holidays, she asks the postman, Mr Martin, to drop Dr Smith's post directly in to Dr Smith.

When asked, Mrs Moore explained that, given her experience, she knows how to recognise bad or poor test results. She confirmed that she did not see the Lung Function Test results for Mrs Brown when they arrived in the hospital. She said that the particular results must have gone astray.

She said that, if she had opened the envelope with Mrs Brown's LFT results, she would have recognised that they were abnormal. She said that she would have telephoned Dr Smith and advised him of the contents of same and her concerns.

Mrs Moore was asked if anyone in the typing pool would ring her if they had concerns that post or other items were building up in Dr Smith's postal slot. In response, she confirmed that more recently Dr Smith's public secretary in the typing pool would ring advising that there were letters or items awaiting signature. She said that, in those cases, his public secretary would ring Dr Smith directly, as she has a direct reporting line to Dr Smith.

In relation to date stamping post items, Mrs Moore confirmed that she has a "date stamper" but that she doesn't use it. She said that, in future, she probably will use it.

Mrs Moore emphasised that there is no difference in the treatment of post items in respect of private and public patients. She said that, regardless of whether the correspondence was in respect of a public or a private patient, once Dr Smith's name is on the envelope, it would come straight to her. She again confirmed that this was the case from 2 or 3 months after she took up duty in January 2002.

In relation to the issue of pre-alerts, Mrs Moore explained that if Dr Smith was worried about a particular case, and if it involved a private patient, he would ask her to look out for the results. She said that she has a general overview of all Dr Smith's private patients, as she gets to meet all of them in his rooms in Castlebar every Monday.

Mr Martin, Postman, Mayo General Hospital, Castlebar

Mr Martin's main job is to deal with the hospital's post, a position he has held for over 11 years.

He explained that the volume of post received per day is substantial. Some post also arrives by courier. Inter-hospital post from Mayo General Hospital is sent in a taxi each day, (Monday to Friday) to Merlin Park Hospital, Galway and to University College Hospital, Galway. The taxi then returns from each of these two hospitals with post for Mayo General Hospital. The taxi arrives back in Mayo General Hospital between 3 and 3.30pm, each day

He said that any post which is specifically addressed to a doctor, goes straight to that doctor. He does not open letters or any post which has a doctor's name on it. He confirmed that this has always been the procedure. He said, however, that originally, all post went to the Consultants' Post room - Rest Room - but that this procedure was changed in 2003 . He now leaves the Consultants' post wherever the particular Consultants requests him to leave it.

He said that all post which is addressed to Dr Smith goes directly to Mrs Moore, Dr Smith's personal secretary,except for those letters which are marked "appointments", which go to the Medical Registrar.

Mr Martin stated that, originally, he would leave post in the typing pool for Dr Smith, but that, once Mrs Moore became Dr Smith's personal secretary, he was asked to give all post, which was marked for Dr Smith's attention, to Mrs Moore. He pointed out that there is a different arrangement for other Consultants. His general approach is to leave the post wherever he is asked to by the Consultant, in order to suit the particular Consultant's wishes and requirements.

He explained that he also leaves post in the postal slot in the typing pool. He stated that it is up to the particular consultants to take the post out of their own assigned postal slot.

When asked to explain what happens to post items which are for Dr Smith - but where this is not apparent from the envelope - Mr Martin explained that it would go to the Hospital Manager's secretary, for her to decide and for her to re-direct it to its intended destination.

Mr Martin stated that since 2004, no post with Dr Smith's name on it would have gone to the postal slot in the typing pool.

When asked if it was possible that any post items could have gone to Mrs Moore's office and then have been referred back to the typing pool where they might then have been put in the postal slot, Mr Martin said that this was not possible. He said that, if any post item was referred to Mrs Moore by him in error, she would re-direct it back to him for re-checking, if that was the case.