Numerous failures meant opportunities to address issues in the work of Dr Michael Watt were missed for many years and on multiple occasions, a public inquiry has found.
The Independent Neurology Inquiry published its final report on Tuesday morning and made a damning assessment of a series of failures to intervene and protect patients.
The inquiry, which has made 76 recommendations, was set up to examine the biggest recall of patients in Northern Ireland.
The care of more than 5,000 former patients of Dr Watt has been reviewed.
The report said: “While one process or system failure may not be critical, the synergistic effect of numerous failures ensured that a problem with an individual doctor’s practice was missed for many years, and, as this inquiry finds, opportunities to intervene, particularly in 2006/07, 2012/13, and earlier in 2016 were lost.”
The inquiry was critical of the Belfast Trust and said it “could and should have intervened earlier but failed to do so”.
It found the trust had “sufficient information” prior to 2016 - when partial restrictions were imposed on Dr Watt’s work in December, “to demonstrate a pattern of potential aberrant practice”.
It also found significant evidence “that concerns had been raised and had not been appropriately managed or further escalated on numerous occasions”.
The Belfast Trust has apologised to the patients who “suffered avoidable and unnecessary harm whilst under the care of Dr Watt”. A statement said: “We are wholly and unreservedly sorry that occurred.”
The inquiry said a number of doctors had raised concerns, including in 2013 when a registrar brought to the attention of the then clinical lead for neurology that a pregnant woman had been inappropriately diagnosed with epilepsy.
It said concerns were either not escalated or recorded properly.
It continued: “Key information was known to only one or a small number of individuals, who commonly analysed that information in a vacuum and determined that it was a one-off, insufficiently serious, or irrelevant, without the benefit of the broader picture.
“This resulted in concerns not being escalated, and when they were, not being analysed in their full and proper context.”
It said the “failure to learn from complaints was one of the more disturbing aspects of the investigation conducted by this inquiry”.
It continued: “The sober reality is that the complaints system within the Belfast Trust was inadequate in terms of identifying patient safety concerns.”
The inquiry said a “perception that Dr Watt’s clinical ability was not in question” contributed to the belief that any concerns about his work was administrative.
However, it noted he had a history of failing to comply with appraisals of his work or requests for reports by coroners, insurance companies and the General Medical Council.
It explained that this may be “indicative of an attitude which needed to be challenged more robustly at an earlier stage”.
It said “problems in the trust systems are illustrated graphically” by the fact it was a GP and not someone who raised concerns about Dr Watt in November 2016.
However, it did not limit its criticism to the trust and said a clinical complaint by the General Medical Council (GMC) in 2012 “was essentially dismissed”.
An internal review carried out by the GMC in 2019 said it had “not been properly investigated”.
It also revealed that Dr Watt received a five-year warning from the GMC but this was not communicated to Dr Watt’s line managers at the trust.
The inquiry also raised concerns that private providers did not bring to the attention of the person responsible for reviewing Dr Watt’s work concerns about his clinical practice.
“Critical information at key times was not passed on to the Belfast Trust by the Ulster Independent Clinic,” it said.
It also raised concerns about the fact Dr Watt was essentially working alone at a time when there were restrictions on his clinical practice, which it said “contributed to the problems that developed in his practice”.
“This arrangement does not seem to have been reflected upon or regarded by management as unusual or problematic,” it explained.
Referring to Dr Watt’s use of blood patch procedures, the inquiry described the dramatic rise in the procedures between 2014 and 2017 as “truly extraordinary”.
It also said the increase in blood patch procedures was “carried out in plain sight of his colleagues and other medical staff” and that Dr Watt never tried to hide what he was doing.
“None of the existing management arrangements were effective in querying or questioning the proliferation of blood patch procedures by Dr Watt,” it said.
It also highlighted a “medical culture” which it said, “discouraged concerns being escalated or the questioning of the actions of such a senior consultant”.
Similar reluctance to challenge a senior medic’s prescribing patterns was also identified, while the inquiry also said concerns about a high level of prescribing of a medication was “largely dismissed by the clinical director”.
Among the recommendations made the inquiry are that the Department of Health and GMC make a joint public statement to reassure the public that current appraisal processes are adequate to ensure patient safety.
Greater emphasis should be placed on improving patient safety when complaints are made, it has said.
The inquiry has also said the response to a complaint should not be determined by the doctor, as it found was frequently the case with Dr Watt.
In a statement, chief executive of the Belfast Trust Dr Cathy Jack said to the patients of Dr Watt and their families: “The Belfast Trust let you down and many of you have suffered avoidable and unnecessary harm as a result. Whether that was through being given a diagnosis that was not correct, receiving incorrect treatment or medication, or having a procedure you did not need. For that I am truly sorry.
"That is not what the Belfast Trust wants for its hundreds of thousands of patients, cared for in a wide variety of ways by a dedicated staff. It is why that I, and my executive team, are determined to continue to work to improve the governance systems that we have in place to reduce, as far as we possibly can, the risk of something like this happening again.”
Chairman of Belfast Trust, Peter McNaney said: “The Inquiry’s Report is extensive and detailed and the Trust will need time to fully consider and reflect on its findings. While the Report highlights there were a number of missed opportunities in the past to enquire further into Michael Watt’s practice it also recognises the decisive action taken in 2017 by Dr Cathy Jack (the Trust’s then Medical Director) to commission an independent review by the Royal College of Physicians, which led to Michael Watt’s practice being fully restricted.
“Through engagement with the work of the Inquiry the Trust has already taken steps to address some of its concerns including the introduction of clinical record review and a professional governance information system which collates and pulls together in one place all the information the Trust holds about its doctors.
“The Trust will fully engage with the Department of Health and the entire HSC in considering any further action that might be required.”