Report Reveals Most Common Clinical Incidents in Ireland

The State Claims Agency has published a report revealing the most common clinical incidents in Ireland and the cost of settling clinical negligence claims.

The report – National Clinical Incidents, Claims and Costs – covers the period between 2010 and 2014. Its purpose, according to lead author Dr Dubhfeasa Slattery, is to help improve patient safety by analysing national data on clinical incidents in Ireland, and studying the results in order to develop a “learning health system” that provides safer care.

More than 206,000 clinical incidents in Ireland were reported to the State Claims Agency over the five year period – not all of which were attributable to medical negligence, and therefore not all resulting in clinical negligence claims. The incidents were divided into five main categories – Medicine, Surgery, Maternity Services, Disability Services and Care of the Elderly.

In the Medicine category – the category in which most clinical incidents were reported – the most common adverse outcomes were attributable to a delay or failure to diagnose and treat (most often in the emergency room), the incorrect medicine or dosage of medicine being prescribed or administered, and serious soft tissue damage – typically caused by bed sores due to a lack of nursing care.

Among the most common surgical clinical incidents in Ireland, the delay or failure to treat was again the leading cause of adverse outcomes. However the high percentage of adverse outcomes attributable to faulty equipment and missing or misplaced clinical records was also a cause for concern – both in the Surgery category and the Maternity Services category.

The leading clinical incidents in Ireland in the Maternity Services category were post-partum haemorrhages and perineal tears, while medication issues and serious soft tissue damage dominated the clinical incidents in the Disability Services and Care of the Elderly categories. A further 66,000 medical incidents were reported to the State Claims Agency during the period being investigated that were not regarded to be of a clinical nature.

In relation to the number of clinical negligence claims made during the period and the cost of settling them, the figures quoted in the report (2,873 claims and €288 million in settlement costs) are misleading as they included claims made during the period not settled during the period, and pre-2010 claims settled between 2010 and 2014. They were also inflated during 2012 by DePuy hip replacement claims, the Lourdes Redress scheme, and by the volume of claims made for unnecessary symphysiotomy procedures.


New Symphysiotomy Compensation Plan Announced

The Government has proposed a new symphysiotomy compensation plan after its U-turn on extending the Statute of Limitations for women who underwent the procedure between the 1940s and 1980s.

Minister for Health Dr James Reilly announced in a press conference that Judge Yvonne Murphy has been asked to examine the feasibility of a compensation scheme for women who underwent the controversial childbirth procedure, and who have been left with permanent injuries such as incontinence, difficulty with walking and chronic pain.

Judge Murphy has been asked to compile a series of compensation options for review in February 2014, to “assist in finding closure” for the women affected by the operation. Dr Reilly said that the Government would contribute to an ex gratia scheme if that is the symphysiotomy compensation plan recommended, and it is understood that Judge Murphy will be meeting with insurance companies to explore whether they would contribute towards such a scheme.

Originally Dr Reilly had said he would not oppose a private members bill introduced into the Dáil by Sinn Féin’s Health Spokesman Caoimhghín Ó Caoláin to allow a one-year window for the affected women to make claims for symphysiotomy compensation; however the Government were then told that such a move could result in a legal challenge by the insurance companies who would have been liable for compensating the women.

Sinn Féin’s health spokesman Caoimhghín Ó Caoláin criticised plans to keep the statute of limitations in place. He said “The type of scheme outlined in the terms of reference offers the women no prospect of adequate compensation for what was so barbarically done to them nor the choice to pursue their rights in the courts.”

However Chairman of the support group Survivors of Symphysiotomy Ltd – Tom Moran – welcomed the announcement of a new symphysiotomy compensation plan. His comment was “We welcome this decision to appoint the judge and we hope it leads to women finally being given a chance of some kind of closure.”


Woman Awarded Compensation for Injuries from Symphysiotomy

A woman, who underwent a symphysiotomy procedure at Our Lady of Lourdes Hospital in 2000, has been awarded €591,297 compensation for injuries from symphysiotomy by the High Court.

Tracey Nelson (45) from Navan in County Meath underwent the procedure prior to the delivery of her second child, when medical staff at Our Lady of Lourdes Hospital in Drogheda failed to correctly diagnose the symptoms of symphysis pubis dysfunction (SPD).

After suffering for many years with the physical discomfort from the symphysiotomy, Tracey underwent surgery in 2004 to stabilise her condition and again, in 2007, had to have a spinal cord stimulator fitted – since when Tracey has been relatively free of pain.

However, as Tracey related to Mr Justice Iarfhlaith O’Neill at the High Court, she has also suffered emotionally due to the negligence of the medical staff who failed in their duty of care to manage her pregnancy.

Tracey told the court she had developed fibromyalgia – where she had constant pain in her muscles and joints – and due to the pain, started to drink alcohol heavily. This resulted in the break-up of her marriage and, in turn, to depression.

Our Lady of Lourdes Hospital denied their liability for Tracey´s injuries, but Mr Justice Iarfhlaith O’Neill ruled that he was satisfied from the medical evidence there was a failure to diagnose SPD on February 2nd when Tracey attended the hospital complaining of pain in the pelvic area.

The judge said there was no doubt that the “primary cause” of Tracey´s physical and psychological injuries was the negligence of the HSE and “terrible consequences” of it. “I am quite satisfied that the failures in this regard fell substantially below the standard of care to be expected of doctors practising obstetrics in a maternity unit such as Our Lady of Lourdes in Drogheda,” he said.

Awarding Tracey €591,297 in compensation for injuries from symphysiotomy, Mr Justice Iarfhlaith O’Neill said that he was also satisfied the doctors and midwives who attended Ms Nelson were “oblivious” to her SPD condition and consequently took no precautions to prevent the risk of avoidable injury during the course of her labour.


High Court Awards Compensation for a Failed Sterilisation

The High Court has awarded a mother €100,000 compensation for a failed sterilisation after the son she was never supposed to give birth to died after only six months of life.

Karen Hurley-Ahern (41) from Newcastlewest, County Limerick, underwent the sterilisation procedure in February 2001 after discovering from her GP that she had a rare blood-clotting disorder that would pose a risk to herself and her unborn child if ever she were to fall pregnant again.

The operation was performed by gynaecologist Dr Victor Moore at the Tralee General Hospital in County Kerry, but in April 2002 Karen fell pregnant again and, after a difficult pregnancy, gave birth to baby Samuel on 10th October 2002 – six weeks early and by emergency Caesarean section.

Samuel suffered from severe abnormalities which were unrelated to Karen´s sterilisation procedure, and remained in hospital for six months – kept alive by a series of life -support machines. In April 2003, Samuel suffered a severe heart attack and Karen and her partner – Garrett Ahern – made the painful decision to switch off the life-support machines.

After seeking legal advice, Karen and Garrett made a claim for failed sterilisation compensation against Dr Moore and the Southern Health Board (now the Health Service Executive), for the suffering and trauma the couple had been through due to the unsuccessful procedure.

Dr Moore and the HSE denied liability – claiming that the procedure had been performed correctly and the couple had been warned that there was a risk of failure. However, in the High Court in Dublin, Mr Justice Sean Ryan found in favour of the now-separated claimants – acknowledging that Samuel´s disability was not a consequence of the failed sterilisation procedure, but stating that Karen had suffered to a significant extent due to the defendant´s negligence.

Awarding Karen €100,000 compensation for a failed sterilisation, Mr Justice Sean Ryan said that the award of compensation was in respect of the worry she had experienced when she discovered she was pregnant, the pain of childbirth, the distress of Samuel´s condition and distress after his death. However, no award was made to Garrett as – according to Mt Justice Sean Ryan – while he had undoubtedly endured emotional anguish, there was no proof Garrett had suffered a defined psychiatric injury.


Claim for Death after Caesarean made against HSE

A widower, who lost his wife after she had given birth to their son via a C-section procedure, has made a claim for death after Caesarean against the Health Service Executive.

Dhara Kivlehan (29) from Dromahair, County Sligo, gave birth to her son – Dior – on 21st September 2010 at Sligo General Hospital via a Caesarean section operation but, soon after the procedure, developed multiple organ failure secondary to HELLP syndrome – a variant of pre-eclampsia. Dhara was rushed to Belfast´s Royal Victoria Hospital to receive specialist treatment, but died on September 29th.

Dhara´s husband – Kevin Kivlehan (33) – asked the Belfast Coroner John Lecky for an inquest into his wife´s death, but his request was turned down. Now he has asked the Coroner for Sligo to investigate the circumstances of his wife´s death and made a claim for death after Caesarean against the Health Service Executive (HSE).

No decision has yet been made by the Sligo Coroner, but the HSE is expected to defend themselves against the claim for death after Caesarean, and the alleged breach of duty and alleged negligence claimed by Kevin Kivlehan, after the symptoms of hemolysis, elevated liver enzymes and a low latelet count were allegedly not identified and treated in time to prevent his wife´s death.

A High Court decision on whether the HSE have a case to answer in respect of the claim for death after Caesarean is expected soon.


Claim for Plastic Surgery Errors Settled for Undisclosed Sum

A woman, who was just hours from death after contracting an infection during a breast enlargement operation, has had her claim for plastic surgery errors settled for an undisclosed sum.

Kate Murray (28) from Dun Laoghaire, Dublin, made her claim for plastic surgery errors after undergoing surgery at the Cosmedico Clinic in Kilmacanogue, County Wicklow on 15th March 2008; within three days of which she had started to experience pains across her abdomen and chest and started vomiting.

On 20th March, Kate returned to the clinic, where she was examined by her surgeon – Marco Loiacono – and advised that there were no signs of infection. However Kate was forced to return to the clinic each day for the next five days to have her wounds dressed, as they were seeping yellow-green fluid and blisters were developing on other areas of her breasts.

On none of these latter occasions was Kate attended to by Mr Loiacono, and it was not until the 31st March that Loiacono acknowledged that something may have gone wrong during the original plastic surgery. An emergency operation was organised and Kate´s breast implants were removed that evening.

However, Kate continued to suffer severe pain and, on 3rd April, Kate´s mother summoned her GP. The GP had Kate rushed to St. Vincent´s University Hospital where doctors discovered a severe infection on her chest, in her back and in her stomach.

Kate was diagnosed with such a severe case of “sepsis and extreme infection” that, at a later Irish Medical Council´s Fitness to Practice committee, consultant surgeon Denis Evoy testified that the infection could have killed Kate if she had been hospitalised nine hours later.

Mr Loiacono was barred from practising medicine by the Irish Medical Council in 2011 after he was found guilty of professional misconduct and, although she has to still go through many years of reconstructive surgery, Kate made a claim for plastic surgery errors against both Mr Loiacono and the Cosmedico Clinic.

With liability already established, the High Court was due to hear Kate´s claim for plastic surgery errors for the assessment of damages only but, with neither Kate nor Mr Loiacono present in court, the announcement was made that the case had been settled for an undisclosed sum.


Symphysiotomy Operation Compensation Awarded in High Court

A woman who underwent an unnecessary symphysiotomy procedure in 1969 has had a settlement of symphysiotomy operation compensation awarded in the High Court.

Olivia Kearney (60) of Castlebellingham in County Louth underwent the operation at Our Lady of Lourdes Hospital in Drogheda when she was just eighteen years of age following the birth of her first, and only, child. In 2002, Olivia heard a news program on the radio in which the presenter was relating experiences of woman who had undergone the symphysiotomy procedure – often without knowledge or consent – and many of the symptoms coincided with what she had experienced since her child had been born.

After obtaining her medical records and seeking legal advice, Olivia made a claim for symphysiotomy operation compensation against Our Lady of Lourdes Hospital in 2004. However, when her case was originally heard in the High Court in 2006, the judge dismissed the claim on the grounds that “there would have to be expert evidence available on both sides to debate the appropriateness of the procedure carried out” and, as the surgeon who performed the procedure without Olivia´s consent, the anaesthetist, radiologist and senior house officer had since died, the circumstances and the necessity for the symphysiotomy operation could not be explained.

Olivia revised her claim for symphysiotomy operation compensation on the grounds that the procedure had been carried out after her child had been delivered by Caesarean Section and that there was “no justification, whatever, in any circumstances, for the carrying out of a symphysiotomy operation [on Ms Kearney] at the time it was performed and following delivery by Caesarean Section”. On appeal to the Supreme Court, Olivia was given leave to re-introduce her symphysiotomy compensation claim and, at the High Court, her case was presented in front of Mr Justice Sean Ryan.

Having heard that Our Lady of Lourdes Hospital could produce no evidence which would explain why the unnecessary procedure was performed, Mr Justice Sean Ryan awarded Olivia 450,000 Euros in symphysiotomy operation compensation against the Medical Missionaries of Mary who ran the Our Lady of Lourdes Hospital, commenting that that Olivia had suffered a lifetime of “pain, discomfort and embarrassment” due to the unnecessary symphysiotomy operation.


Poor Follow Up on Hospital Tests Exposes Hospitals and HSE to Significant Negligence Claims

Dr. Muiris Houston, writing in the Irish Times today, has raised serious concerns about poor follow up on hospital tests. His comments follow a project carried out by researchers from the University of New South Wales in Sydney, Australia, on studies which examined the impact of missed test results published between 1990 and 2010.
Their research found that the lack of follow up on hospital tests for inpatients in some areas was as high as 60 per cent, while one study revealed that tests carried out on patients in an emergency department were not followed up 75 per cent of the time. A further study of medical negligence claims revealed that 71 per cent of claims were due to a missed diagnosis while in emergency care, which later resulted in some form of harm to the patient.
The report, which was published in the BMJ Quality and Safety Journal, highlights a particular problem when patients are discharged from hospital and either into outpatient care or into the care of their GP. The tests which are most commonly overlooked include blood tests and diagnostic imaging such as X-rays and scans, with the consequences of these hospital tests not being followed up being potentially missed cancer diagnoses, inappropriate antibiotic treatments and the development of osteoporosis.
Dr. Houston pointed out in his article the relevance of these findings in Ireland, and cited recent cases such as the Hayes Investigation into the Tallaght Hospital which found evidence of 57.921 unreported x-ray films dating back to 2003, and the tragic cases of Ann Moriarty and Edel Kelly who died from cancer shortly after being given the all-clear from Ennis County Hospital in 2008 and after abnormal blood test results were filed and not acted upon.
Dr. Houston, who is a clinical fellow with the Department of Medicine at the National University of Ireland, Galway, feels in his article that missed test results are a substantial problem and raises concern about public safety – a theme often mentioned in his TV and radio appearances, and one which features in his book “Your Work; Your Health”.


HSE Apologises For Surgical Errors: Admits Liability in High Court Case

The Health Services Executive (HSE) has apologised in the High Court for surgical errors that lead to the death of Michael Devane of Killarney, County Kerry. Mr. Devane died in October 2007 after broken wrist surgery in Kerry General Hospital, Tralee, County Kerry.  Devane’s airways became blocked while under general anaesthetic and he was unable to breath, resulting in brain injuries and death nine days after the operation.
At the High Court, Ms Justice Maureen Clark heard that the family of the deceased had claimed the HSE had failed in its duty of care by proceeding with the operation when it was known that no recovery room was available and subsequently failed to monitor the post-operative effects of the anaesthetic.
In its apology, the HSE said it “wishes to apologise sincerely to Mrs Deborah Devane and the entire Devane family for the various failings in the treatment and care afforded to Michael by Kerry General Hospital in Tralee on September 27 and the days afterwards.” The HSE acknowledged that “nothing can make up to the Devane family for the tragic loss of Michael who was a devoted and dedicated father and family member.” 
Ms Justice Maureen Clark was informed that the HSE admitted liability, actions had been settled and the case was before the courts for assessment only. No details of the settlement were disclosed in open court. 


At least 19 Wrong Body Part Operation Errors in HSE Hospitals

Investigative journalists at the Irish Independent have revealed there has been at least 19 wrong body part errrors by surgeons  in  Health Service Executive (HSE) hospitals between 2005 and 2010.  Wrong body part surgical errors, sometimes called wrong-site surgeries, occur when a surgeon operates on the wrong part of a patient. The surgical errors in the HSE hospitals included operations on the wrong eye, ovary, kidney, leg, hand, and finger.

The HSE has already paid six hospital negligence claims as a result of the wrong body part operations, including a case where a surgeon in Our Lady’s Children’s Hospital in Crumlin removed the wrong kidney of a boy in March 2008, leaving him requiring dialysis until he gets a kidney transplant.

Ireland has operated a centralised database since 2000 to which all adverse clinical incidents must be reported.  The data on wrong body part errors came from this database. The system means that while patients may not be fully informed and aware that they suffered some sort of clinical incident while receiving treatment in an Irish hospital, the error will be reported and logged in the centralised database.


Hospital Negligence Statute of Limitations Rules Updated

Ms Justice Elizabeth Dunne has made an important ruling in the High Court regarding the definition of “date of knowledge” for medical negligence claims and hospital negligence claims. The 1957 Statute of Limitations Act has been updated to reduce the time from “date of knowedge” to making injury claims to two years (rules are different for child injury claims).
However, Ms Justice Dunne ruled that an individual may be aware of an injury but not be aware that it was caused by negligence. Specifically, Justice Dunne said that in the case of Edward Naessens that it was “very difficult to accept” that the victim had the necessary medical expertise to decide if a recurrence of a tumour was due to medical negligence.
In this particular case, the victim Edward Naessens had an operation in February 1994 for an adenoid cystic carcinoma (removing a cancer tumour) but was told that no further treatment was required apart from six-montly reviews. He was told in 1996 that additional pain was due to scar tissue and nerve damage. It was only after a recurrence in 2000, after which he received comprehensive post-operation care in St. James’ Hospital, that Naessens realised that he had not received the same level of care previously. Specifically, it was claimed that after his first operation, Neassens should have received additional radiation treatment and a CT scan when he complained of pain, in addition to being advised about the high risk of a recurrence of cancer.
The defendants were the CEO and a consultant surgeon at St. Vincent’s Hospital, who had requested that the court rule that the case was statute barred.
The decision now means that not all medical negligence claims are automatically subject to the two year Statute of Limitations rule.  It also confirms that judges do indeed have full discretion regarding interpretation of the rules in the interest of serving justice when there are special circumstances.


Family Receives 564,000 Euro Compensation for Hospital Death

The family of Miriam Jackson of Navan, County Meath, has received a €564,000 High Court settlement following her death in September 2004 in Our Lady’s Hospital, Navan, two weeks after being admitted with a small bowel obstruction. The case was taken by her husband, Derek Jackson, who also sued on behalf of his three children for damages for the loss of Mrs Jackson and the resulting mental distress. The lawsuit outlined over twenty claims of medical negligence and hospital negligence – mostly an unfortunate list of ignored symptoms. It was alleged that that urine analysis results were ignored – results that found an E coli infection and therefore septicemia was allowed develop and go untreated for a significant period of time. It was alleged that Mrs Jackson complained of abdominal pain and was feverish. It was claimed that her rising temperature was ignored by the surgical team. It was alleged that a medical consultation requested by the surgical registrar did not take place, despite multiple symptoms, including a temperature of 38.2 degrees, chest tightness, shortness of breath, and light-headednes.
The hospital admitted liability in the case, so the High Court case under Mr Justice Iarfhlaith O’Neill was only to determine the amount of compensation.


Family Receives 2.4 Million for Surgery Death

The  family of the late Kay Cregan, a mother of two from County Limerick, has agreed to a legal settlement of $3.1m (€2.4m) following her death during cosmetic surgery.  The incident was particularly shocking because Mrs. Cregan had not informed her husband, Liam Cregan, that she was undergoing a facelift during her visit to New York in March 2005.

A jury found anaesthesiologist Dr. Madhavrao Subbarao and nurse Susan Alonzo Francisco guilty of not implementing best medical practice in her post-operative care.  However, the jury did not find that the anaesthesiologist and nurse were responsible for Mrs. Cregan’s death.

The plastic surgeon, Dr. Michael Evans Sachs, had been involved in 30 malpractice cases in 10 years prior to surrendering his licence to practice to the medical regulatory authorities in New York State.  The settlement consisted of a $2.1m (€1.6m) settlement with Dr. Sachs’s insurance company and $1m (€769,000) with lawyers representing nurse Susan Alonzo Francisco.