Endoscopy: Alarm Bells Were Ignored

An independent review of failings in the endoscopy service, made public for the first time, shows alarm bells were raised numerous times by clinicians.

The confidential report, completed in March this year, has now been published on the government website following a request made to Health Minister David Ashford in the House of Keys.

It was commissioned the previous year after it emerged that 157 patients had potentially been affected by delays to follow-up colonoscopy appointments between 2014 and 2017.

As the Isle of Man Examiner reported last month, the island’s Health and Care Association believes there was a ‘complete failure’ to carry out follow-up endoscopy from as far back as 2011, with some bowel patients forgotten and reminders ignored.

Some may have subsequently died from undiagnosed bowel disease, HACA believes.

Now the independent report carried out by MiAA Advisory Services reveals that warnings by clinical staff were not acted upon.

There had been a series of alerts to potential patient safety risks but these ‘did not trigger an appropriate response via corporate risk management systems’, it confirms.

The report cites emails involving clinicians and managers which MiAA said ‘raise obvious alarm bells’ and present ‘missed opportunities to delve deeper or ask searching questions’.

One from March 2017, reads: ‘I am taking the liberty to email once again [to] highlight my concerns and solicit very urgent action. We have many patients with very high risk of cancer who are not receiving any endoscopy surveillance.’

Another email, from July 2016, suggests patients were deliberately kept in the dark.

waiting list

It reads: ‘Make sure that no precise information is passed to patients regarding their waiting list for endoscopy.

‘In particular, we should avoid giving them false hopes or generating panic.’

HACA, a registered charity that supports patients who have initiated complaints about their care, said the ‘whole, sorry tale, highlights a long-standing failure/incompetence of management within health and lack of political leadership and effectiveness’.

It said it is ‘staggering’ that it had taken ‘so many years, with so much going wrong, with so many concerns being raised’ for the Health Minister to tell Tynwald in May this year that his department could not be faulted for taking the issue seriously.

And the charity said the MiAA report suggests there has been a significant culture within the hospital that actively discourages whistleblowing or suppresses escalation of staff concerns.

The independent report confirms there were weaknesses in both the design and operational effectiveness of the controls in place for the endoscopy service during the critical period from 2014-2017.

It found there was an incomplete set of coherent procedures and protocols.

‘A serious risk to patients materialised,’ the MiAA report concludes.

‘The endoscopy service was under pressure for a prolonged period and concerns were being expressed. The actual risks to patients were not formally reported/identified until 2017 despite corporate governance and reporting systems being in place.

‘This would suggest that these systems were/are weak or being regarded or used as intended.’

The Health Minister said that since it was discovered in April 2017 that 157 patients had not had follow-up appointments as they should, a programme was then put in place to give them all follow-ups. This was completed by August that year.

He insisted there have been no issues since then and there are no individuals still waiting years for a follow-up appointment.

But according to the Isle of Man HACA, there is evidence that things may not be getting any better.

A spokesman said: ‘It is difficult to see if what is in place now is any different/better.

‘The implied lack of action after the West Midlands review is of great concern. It suggests the lessons of, and appreciation of, proper governance, open reporting of performance and performance management are still not in place.

‘The MiAA report alludes to similar issues in other patient safety critical areas such as MRI and stroke thrombolysis. Both are areas that our “soft intelligence” has previously noted as “of concern”.

‘We are pressing for regular publication of data, independent monitoring and independent oversight of performance.’

The HACA has also said that, following the initial report in the Examiner on December 11 about ‘failure of care’, ‘a number of other patients affected [by endoscopy follow up delays] have been in touch with us.’

Source: IOM Today