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HSE publishes External Review by Professor Robert JC Steele of Safety Incident Management response to Wexford General Hospital bowel screening incident

The HSE has today, Wednesday 24th January 2018 published the External Review of the overall management of the serious incident regarding missed cancers at Wexford General Hospital (WGH) which occurred while carrying out procedures under contract to the BowelScreen programme in 2013. The Review was carried out by Professor Robert JC Steele, Senior Research Professor in prevention, early detection and treatment of colorectal cancer at the University of Dundee.

The Safety Incident Management Team report (SIMT) which was examined by Professor Steele as part of his review, was published by the HSE in January 2017. The SIMT report outlined the process followed in carrying out a thorough review of colonoscopies under the care of an individual consultant at WGH, including the recall of all patients concerned, together with a list of key recommendations to improve patient safety.

Given the gravity and scale of the incident, the HSE deemed it appropriate and necessary to commission an independent expert to review the overall management of the incident and to provide confirmation that appropriate quality assurance was in place.

In his review, Professor Steele assessed the governance and management of the safety incident and the look back process that was undertaken. He also undertook an examination of the current governance arrangements pertaining to Quality Assurance (QA) between BowelScreen and those hospitals that provide colonoscopy services for BowelScreen.

Commenting on his review Professor Steele said, “While recognising the significant effect of this incident for the patients and families affected, it is clear that the bowel screening team has learned a great deal to the benefit of the bowel screening programme in Ireland. I want to reassure the Irish public that all Quality Assurance processes were appropriate at the time of the review and that BowelScreen has committed to the introduction of further measures to enhance programme quality and patient safety.”

Professor Steele also found that the process followed by the Serious Incident Management Team (SIMT) to manage the incident and to bring it to a conclusion, was well managed and that the governance structures and lines of accountability and authority were clear. However, he identified missed opportunities in responding to the concerns of a staff member at Wexford General Hospital regarding the standards of an individual clinician’s work, although he indicated that there were mitigating factors giving rise to this.

In response to this finding, BowelScreen have implemented a new policy to manage safety incidents, in order to manage such incidents in a standardised and appropriate manner. BowelScreen have also developed enhanced policies and procedures to strengthen early warning systems and to ensure that a proactive response is taken in all cases where concern is raised by staff.

Dr Stephanie O’Keeffe, HSE National Director for Health and Wellbeing, and co-commissioner of the report said, “On the publication of the SIMT report in January 2017, we acknowledged the seriousness of this incident for the patients and families affected. As a result, we commissioned an external review of all elements of our response to this patient safety incident. Our aim in doing so was to provide reassurance to the patients and families affected. In addition, we wanted to learn from this incident and to make sure that we have robust procedures in place to prevent such an incident happening in the future”.

Following the publication of the SIMT report in January 2017, BowelScreen immediately commenced work on the implementation of all of the recommendations outlined in the report. The majority of these are now completed. To date BowelScreen has:

·         Implemented a new policy to manage safety incidents, so that serious issues are managed in a standardised and appropriate manner;

·         Developed enhanced policies and procedures to strengthen early warning systems and to ensure that a proactive response is taken;

·         Revised the relevant agreements with hospital partners to include all relevant quality assurance guidelines;

·         Augmented and clarified the requirement for detailed clinical audit at local level;

·         Increased the minimum Adenoma Detection Rate (this is the standard measurement of clinical quality in endoscopy) from 25% to 45% and commenced measurement at individual clinician level;

·         Completed the revision of Programme Quality Assurance Guidelines; and

·         Put in place arrangements to commence reporting on interval cancers once the data is available.

These improvements will ensure the on-going provision of a quality clinical service to BowelScreen patients nationwide.

-ENDS-

All media queries should be directed to the HSE Press Office at press@hse.ie or by phone on 01 6352840.

The report on the External Review can be viewed here.

 

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