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Call for review of similar cases after sister’s death

A HOSPITAL consultant whose sister passed away following a delayed cancer diagnosis at Letterkenny University Hospital is calling for a review of similar cases.

Margaret MacMahon, who grew up in Letterkenny but is now living in Bristol, has spent the last two and a half years fighting for acknowledgement that there were serious failings in her sister, Carol MacMahon’s care and for action to be taken to prevent it from happening again.

Carol was 65 years old when she passed away from cancer of the womb (uterus), a treatable condition that was missed because no tissue samples were taken. Carol began complaining of pain and bleeding, two of the most common signs of the condition in 2010 but was not diagnosed until May 2012 with widespread cancer.

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Carol passed away in March 2015 and three months later her younger sister Margaret, who has worked as a consultant for the last 20 years, reported a possible clinical incident to Letterkenny hospital as she had serious concerns about patient safety. Margaret is very involved in clinical governance, conducts clinical investigations in her line of her work and undertakes annual reviews of other specialists’ work.

In November 2015 she received a response from the hospital in Letterkenny with a two page brief summarising Carol’s management and confirmation that the incident was being investigated in Galway.

In July 2016, concerned by the lack of response from Galway, Margaret decided to go down the HSE Disclosures route to obtain information. This revealed claims that there were plans for a family meeting a few months earlier and that telephone calls had taken place but Margaret states that nobody had ever suggested any meeting or telephone conversations. It also revealed that a consultant in Galway was asked to review Carol’s case.

In December 2016 Margaret received an eventual response from the Galway investigation which stated that Carol had taken medication against the hospital’s advice during the medical investigation that influenced their ‘medical management’. Margaret refutes this and stated that it is documented in her sister’s medical records that she had actually stopped taking the drug on different dates by different doctors.

This report did not list the core failings and did not acknowledge any negligent care.

Margaret then wrote to Minister for Health, Simon Harris and the then CEO of the HSE, Tony O’Brien.

She outlined that an adequate incident review had not been completed and again raised her concern for the safety of patients in Donegal. Before Christmas 2016 she was informed that they were approving an independent investigation.

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Alongside this Margaret submitted a complaint to the Medical Council who carried out their own review.

This review took 14 months and found the care in the case was “of an acceptable standard”.

During 2017 the HSE investigators in Dublin maintained contact with Margaret. In July she was invited to review a draft report with various recommendations which she strongly disagreed with on medical grounds. It was not until December 2017 that she was vindicated when finally she received a letter from the HSE’s National Director of Quality assurance and Verification, Patrick Lynch who agreed with her and said that the core requirements for the clinical management of Carol’s condition were not attended to and that the HSE’s own recommendations did not go far enough.

The Clinical director of the HSE’s national women and infant health programme, Dr Peter McKenna then travelled over to Bristol with the Irish Lead for Nursing to meet Margaret and discuss the case and the actual investigation. At a later date he gave her his own separate report outlining failures in the case.

However they did not acknowledge the ‘root cause’ of the incident. They did not amend their report or alter their recommendations despite Mr Lynch’s earlier letter.

In July 2018 Margaret commissioned a UK expert, John Murdoch, an NHS consultant gynecologist to conduct an independent review of the HSE files which outlined very significant failures in the clinical management of her sister.

Mr Murdoch found Carol’s cancer could have been cured if tissue sampling had been taken after abnormalities showed up in an ultrasound and if necessary a hysterectomy could have been carried out. Margaret subsequently sent his report and that of Dr McKenna to the Medical Council but they have told her that their verdict remains as before.

Dr Margaret MacMahon pictured with her colleagues

Speaking to the Donegal News from Bristol this week Margaret said the errors are so significant at different stages of Carol’s investigations that similar cases in Letterkenny should be reviewed.

“Carol’s investigations were a total waste of time because none of them were managed appropriately. This has nothing to do with local resources or local waiting times. The failings are really shocking”. For this reason Margaret said “they should be undertaking a review of similar cases in the hospital”.

“The HSE has a duty of care to protect patients and to investigate clinical incidents appropriately but all three Irish investigations have failed to acknowledge the core failings. The HSE recommendations merely refer to local and national standards of practice which should be upheld anyhow,” she said.

Margaret comes from a medical family, her father was a consultant at the hospital in Letterkenny and her two brothers are also consultants. All siblings are involved in clinical practice.

She said it was very distressing for the family because they were suspicious of failings in their sister’s care as Carol was dying. Margaret said Carol saved for her retirement and was so looking forward to buying her dream home on the Donegal coast.

“She was very accepting of her diagnosis. Nobody ever admitted to Carol that something might have been missed and nobody told her during her visits to the hospital. She died totally oblivious,” added Margaret.

“If she had been told then she would have managed this incident herself and would have been able to defend any allegations against her as well.”

Margaret believes this story is important for women in Donegal and also for patients and relatives who have struggled to get answers when something goes wrong. She said she is appalled by the Irish system and how obstructive it has been towards her efforts to address clinical governance for women in Ireland.

When asked if any action will be taken on the back of Dr McKenna’s report on the failings in the case a Spokesperson for the HSE said: “The HSE’s National Women and Infants Health Programme (NWIHP) is aware of the unfortunate circumstances of this case. Following Dr McKenna’s review of this case, the NWIHP engages with the Saolta Hospital Group on a quarterly basis, discussing all maternity and gynaecology issues.

“There are significant issues with gynaecology capacity nationally and the NWIHP is currently developing a plan to substantially increase capacity, which will reduce the risk of this tragic event reoccurring.”

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