Deficiencies in records management put patients at risk
The Royal Dental Hospital and Belfast Trust "failed in its duty" to report concerns and had extremely serious deficiencies in record management of patients, a major inquiry found.
The final damning report published by the Department of Health yesterday after a two-year inquiry also identified communication failings between health bodies.
It said there were "missed opportunities" to report matters as a Serious Adverse Incident.
What the inquiry found:
* There were serious deficiencies in the quality of care provided by the Oral Medicine Department of the Dental Hospital and Belfast HSC Trust to the patients recalled for review.
These deficiencies may have impacted adversely on the health of some of them to a significant degree and certainly had the potential to do so.
* There was a failure by the trust to communicate fully, effectively and promptly with the other HSC bodies in the appropriate manner and a failure by DHSSPS to be proactive in seeking further communication from the trust. It said these communication failures "contributed to the risk of harm to these patients" as they prevented the allocation of appropriate expertise and resources.
Other key issues highlighted: l There was an extremely serious deficiency in record management with the potential to have a "significant adverse impact on the quality of patient care".
* Consultants undertaking a case review between December 2009 and November 2010 encountered "serious difficulties" due to the lack of availability of patients' records when they required them.
In some cases, records were incomplete and in other cases wholly absent.
* The final report stated that in the course of reviewing 3,062 patients' charts, there were 1,156 unfiled items, 93 charts missing and 161 hospital concerns and difficulties with the appointment system so that patients who required follow-ups could be 'lost'.
* The trust, however, has stated that there were 85 rather than 93 missing charts as eight patients' names/numbers had been duplicated.
Between September 15, 2010 and January 31, 2011, 25 of these missing charts were found.
Between January 31, 2011 and February 2, 2011 a further 35 charts were found.
One of these 35 patients was part of the call-back exercise.
* Staffing levels: there was a 50% reduction in the number of consultant-level staff from 20 to 10 in the period from 2003 to 2010. Dr X was the sole consultant in Oral Medicine in the Dental Hospital and in Northern Ireland and had a huge clinical workload and an academic commitment.
* On April 24, 2008, a patient complained to the trust about the late diagnosis of a cancerous lesion of the mouth while under the care of Dr X at the Dental Hospital.
* The DHSSPS was informed in early December 2009 of the concerns raised in respect of six cases.