I'm not sure that it is acceptable to post this here, but in my opinion this is relevant to the issues of --
However the quality of assurance it gives to the public by this reported review below leaves a lot to be desired IMO.
This tragic, avoidable occurrence shows that qualification and registration do not ensure competence in the professions.
It also shows that even in a profession with an independent oversight administration, serious errors can still occur.
But the appropriateness of the censure imposed or the measures taken to prevent a re-occurrence is unclear.
The Medical Council's actions and the undertakings they requested fall far short of giving me any assurance.
===================================
From the Irish Times online @ [broken link removed]
The Irish Times - Saturday, September 4, 2010
Doctors cleared as inquiry into wrong kidney's removal ends
Related
* Doctors cleared of misconduct in kidney mix-up case | 04/09/2010
In this section »
* Mother got to hospital with multi-organ dysfunction
* Tánaiste plays down row over halt to EU funds for Fás
* Blair says stretching truth for greater good is common sense
EITHNE DONNELLAN Health Correspondent
AN INQUIRY into the fitness to practise of two doctors following the removal of a wrong kidney from a child at Our Lady’s Hospital for Sick Children in Crumlin, Dublin, has ended dramatically.
A fitness to practice committee of the medical council, which was yesterday hearing allegations of professional misconduct against Prof Martin Corbally and junior doctor Sri Paran, adjourned for lunch for half an hour but did not sit in public again for more than two hours. When it did its chairman Dr John Monaghan indicated the case against the doctors was effectively over, even though another witness was due to be called and closing submissions had not been made by all sides.
Dr Monaghan said the committee had decided to invoke Section 67 of the Medical Practitioners Act 2007 under which undertakings could be given by the doctors not to repeat the conduct complained of and no finding of professional misconduct would be made against them.
Patrick Leonard, barrister for the medical council’s chief executive officer, objected, saying it would be “very unusual” to invoke Section 67 at such a late stage in a serious case which was “calling out for” the imposition of sanctions.
But Kevin Cross, legal adviser to the fitness to practise committee, said it was open to the committee to hear the bulk of the evidence before taking this step.
Dr Monaghan said the committee was not satisfied beyond reasonable doubt that the conduct complained of amounted to professional misconduct. There were “a series of catastrophic errors” in the case “but we were not satisfied these represented a malicious intention or that the category of professional misconduct was an appropriate way to deal with this tragic outcome,” he said.
The case centred on the wrongful removal of a healthy kidney from a now eight-year-old boy in March 2008, leaving him with a right kidney with 9 per cent functionality. Evidence was given that the boys’ parents asked hospital staff on at least four occasions to double check which kidney was to be removed before he was brought to theatre.
Prof Corbally and Dr Paran each gave three undertakings to the fitness to practise committee before the case halted – not to undertake surgery again without reviewing X-rays, not to delegate work to other doctors without ensuring they were prepared and trained, and to prepare a joint written guide for the medical council within 12 months on the lessons learned from this case.
As the case ended the boy’s parents stressed lessons had to be learned but the two doctors did not comment. This is understood to be one of the first times Section 67 has been invoked.
===================================
Let's review the first two undertakings; -
Or the fact that these undertaking were all that was apparently requried of the medical practitioners involved, amounting to "I promise I won't do it again".
But the third undertaking takes the biscuit.
And why isn't this "guide" being requested by Monday morning at the latest - are the implications of “a series of catastrophic errors” not clear?
In fact, why is this guide being requrested going forward at all - have the substantive facts of the case not lain bare and uncontested for two years?
One isolated error can be traced to an individual and dealt with - the present case indicates there may be systemic system failure.
How could the HSE be operating a system where possibly unprepared, untrained people undertake operations without looking at x-rays?
How appropriate is this strategy for a Committee ajudicating on people who wield the power of life and death over others?
And remember, this occured in a Profession where people spend years obtaining their qualification - up to 15 years.
The distraught parents of the boy had the strength to look beyond to the lessons learnt but not the consultants - to judge by their lack of comment.
ONQ.
- professional accountability
- the benefits of qualification and registration and
- the giving of assurances assurances to the public,
However the quality of assurance it gives to the public by this reported review below leaves a lot to be desired IMO.
This tragic, avoidable occurrence shows that qualification and registration do not ensure competence in the professions.
It also shows that even in a profession with an independent oversight administration, serious errors can still occur.
But the appropriateness of the censure imposed or the measures taken to prevent a re-occurrence is unclear.
The Medical Council's actions and the undertakings they requested fall far short of giving me any assurance.
===================================
From the Irish Times online @ [broken link removed]
The Irish Times - Saturday, September 4, 2010
Doctors cleared as inquiry into wrong kidney's removal ends
Related
* Doctors cleared of misconduct in kidney mix-up case | 04/09/2010
In this section »
* Mother got to hospital with multi-organ dysfunction
* Tánaiste plays down row over halt to EU funds for Fás
* Blair says stretching truth for greater good is common sense
EITHNE DONNELLAN Health Correspondent
AN INQUIRY into the fitness to practise of two doctors following the removal of a wrong kidney from a child at Our Lady’s Hospital for Sick Children in Crumlin, Dublin, has ended dramatically.
A fitness to practice committee of the medical council, which was yesterday hearing allegations of professional misconduct against Prof Martin Corbally and junior doctor Sri Paran, adjourned for lunch for half an hour but did not sit in public again for more than two hours. When it did its chairman Dr John Monaghan indicated the case against the doctors was effectively over, even though another witness was due to be called and closing submissions had not been made by all sides.
Dr Monaghan said the committee had decided to invoke Section 67 of the Medical Practitioners Act 2007 under which undertakings could be given by the doctors not to repeat the conduct complained of and no finding of professional misconduct would be made against them.
Patrick Leonard, barrister for the medical council’s chief executive officer, objected, saying it would be “very unusual” to invoke Section 67 at such a late stage in a serious case which was “calling out for” the imposition of sanctions.
But Kevin Cross, legal adviser to the fitness to practise committee, said it was open to the committee to hear the bulk of the evidence before taking this step.
Dr Monaghan said the committee was not satisfied beyond reasonable doubt that the conduct complained of amounted to professional misconduct. There were “a series of catastrophic errors” in the case “but we were not satisfied these represented a malicious intention or that the category of professional misconduct was an appropriate way to deal with this tragic outcome,” he said.
The case centred on the wrongful removal of a healthy kidney from a now eight-year-old boy in March 2008, leaving him with a right kidney with 9 per cent functionality. Evidence was given that the boys’ parents asked hospital staff on at least four occasions to double check which kidney was to be removed before he was brought to theatre.
Prof Corbally and Dr Paran each gave three undertakings to the fitness to practise committee before the case halted – not to undertake surgery again without reviewing X-rays, not to delegate work to other doctors without ensuring they were prepared and trained, and to prepare a joint written guide for the medical council within 12 months on the lessons learned from this case.
As the case ended the boy’s parents stressed lessons had to be learned but the two doctors did not comment. This is understood to be one of the first times Section 67 has been invoked.
===================================
Let's review the first two undertakings; -
- not to undertake surgery again without reviewing X-rays
- not to delegate work to other doctors without ensuring they were prepared and trained
Or the fact that these undertaking were all that was apparently requried of the medical practitioners involved, amounting to "I promise I won't do it again".
But the third undertaking takes the biscuit.
- prepare a joint written guide for the medical council within 12 months on the lessons learned from this case.
And why isn't this "guide" being requested by Monday morning at the latest - are the implications of “a series of catastrophic errors” not clear?
In fact, why is this guide being requrested going forward at all - have the substantive facts of the case not lain bare and uncontested for two years?
One isolated error can be traced to an individual and dealt with - the present case indicates there may be systemic system failure.
How could the HSE be operating a system where possibly unprepared, untrained people undertake operations without looking at x-rays?
How appropriate is this strategy for a Committee ajudicating on people who wield the power of life and death over others?
And remember, this occured in a Profession where people spend years obtaining their qualification - up to 15 years.
The distraught parents of the boy had the strength to look beyond to the lessons learnt but not the consultants - to judge by their lack of comment.
ONQ.
Weren't you lucky it wasn't one of your kidneys like that poor child.