Health service still in denial

Standards in Irish medical care is rarely out of the headlines these days, and this week we’re taking a look at an article Mary wrote in 2006 about the topic…

Health service still in denial

November 2nd, 2006

It has been a grim time for the health service over the past few weeks. It seems that there has been one case after another of people either dying or seriously injured as a direct result of medical treatment.

Minister for Health Mary Harney yesterday expressed concern in this newspaper for patient safety in small regional hospitals. However, the extent of medical error in all hospitals, whether big or small, continues to be overlooked. Last week we heard about Elizabeth O’Mullane, who was told she had breast cancer and subsequently had a partial mastectomy. It later transpired that she didn’t have cancer at all. Thus, the operation removing part of her breast was unnecessary and she may be left with long-term health problems as a result. Then there was Alan O’Gorman, the young Dublin man whose stomach was removed after a diagnosis of cancer. All Alan had was an ulcer. His test results had been mixed up with those of an elderly man who did have cancer.

I first met Alan over three years ago, when he told us his story for a Prime Time Investigates programme on medical error. It was not easy for a 20-year-old (as he was then) to go on national television and discuss personal medical details. Alan, however, displayed a determination to ensure that no one else should have to go through the appalling trauma he had suffered. He also decided to take a court case to force someone to take responsibility for his injury. Alan’s case eventually came to court last month. The facts were not disputed, and he is to receive compensation for the severe medical consequences he will have to deal with for the rest of his life. However, what was most striking was that no one involved in Alan’s treatment was prepared to admit liability or take responsibility for the mistake. As a result, Alan has had to go through years of uncertainty as he waited for his case to be resolved.

Michelle Tallon’s parents may be facing similar difficulties. Bernie and Bernard Tallon have spent the past year looking for answers as to why their daughter died at the age of 38 in the James Connolly Memorial Hospital in Blanchardstown. Michelle had cerebral palsy and was unable to speak. She had been cared for all her life by her parents, who were her voice. Admitted to hospital in the summer of 2005 with suspected gastroenteritis, she went steadily downhill, according to her parents. She died two weeks later. Last month, the jury at her inquest recorded a verdict of medical misadventure. What this somewhat archaic term means is that Michelle’s death was the direct result of the medical treatment she received at the hospital. However, the verdict does not provide any further detail, and for Michelle’s parents major questions remain. They had serious complaints with the way their daughter was cared for by the hospital. They hardly left Michelle’s bedside during her stay. They repeatedly asked to see the doctors in charge of their daughter. It took a week before they were seen. They constantly questioned the presence of the nil per oral (NPO) order above Michelle’s bed, meaning that she should not be fed. They were becoming increasingly alarmed by Michelle’s weakened state. The hospital conducted a risk management report into Michelle’s death. Risk management is one of those new processes designed to reassure us that hospitals and medics will be fully open when things go wrong and that mistakes will be learnt from. The report on Michelle deals with the NPO order. It concludes that the absence of “a specific policy relating to the day-to-day management of a ‘nil-by-mouth’ order . . . may have led to the possibility of an order remaining in force for longer than it was intended, either through miscommunication or misunderstanding between medical and nursing staff”. The report does not indicate whether this may have been a factor in her death, which was caused by acute respiratory distress syndrome. Given that the NPO order was such a key concern of Michelle’s parents, the vagueness of the language in the risk management report, the use of words like “may” and “possibility”, does not answer their very legitimate concerns that their daughter was not properly fed in hospital. There are also a number of confusing discrepancies between the contents of the risk-management report and some of the evidence presented at Michelle’s inquest. All of this means that her parents remain in the dark as to what exactly caused Michelle’s death.

And lest anyone think that what happened to Michelle, or to Alan O’Gorman or Elizabeth O’Mullane is a rare or unusual event, it is worth recalling the view of the Department of Health on the extent of medical error in this country. In 2001, it acknowledged that up to six patients each day die in Irish hospitals as a direct result of preventable medical error. Those brave few prepared to battle for answers deserve more from a system still all too willing to bury its mistakes.


This column has been republished by the MRJF with the kind permission of The Irish Times.

The featured image was taken from an article on The