Dublin Coroner returns verdict of medical misadventure in Mater Hospital case.
By Rónán Lynch.
The inquest into the death of Dublin woman Maureen Desmond has indentified a number of ways to improve the early diagnosis of, and continuity of care for, women’s cancers. Dublin Coroner Dr Brian Farrell returned a verdict of medical misadventure in the case of the death of Ms Desmond from complications related to uterine cancer at the Mater Hospital in 2011. Stephen Desmond, son of the late Mrs. Desmond has indicated that he intends to take a civil action against the Mater Hospital.
The coroner delivered his verdict on September 26, a year after the first hearing of the inquest, and raised issues about lack of clarity in communications between staff and the patient, and missed opportunities for an earlier diagnosis of the cancer that led to Ms Desmond’s death. Ms Desmond’s son Stephen told the inquest of the difficulty he had experienced in gathering his mother’s medical records, and the inquest found that there was no clarity about the hospital’s claims to have made several appointments with Ms Desmond which she did not attend. Ms Desmond’s son Stephen said that they had received no notification of these appointments.
The coroner said that a verdict of medical misadventure had no implications of misconduct or negligence, but that his remit included making findings where he could identify what he called “risk factors” that may have altered the outcome of the case. Evidence presented to the inquest showed that there were opportunities for earlier intervention in Ms Desmond’s care – including an opportunity to review her case following the emergence of discrepancies between scans in 2007 and a hysteroscopy in 2008, and an opportunity to diagnose cancer on a CT colonogram in 2009.
The coroner’s expert witness told the inquest that it was likely that Ms Desmond already had early-stage endometrial cancer when she first presented to the Mater Hospital in 2008. Despite several tests, the cancer was not identified until the summer of 2010, by which stage it was inoperable stage-three cancer.
Evidence presented during the year-long inquest, which the coroner described as very complex, highlighted the problem with accurate and early diagnosis of uterine cancer in postmenopausal women. The inquest, which began in September 2013, heard that in 2007 Ms Desmond began experiencing abdominal pains and cramps and a vaginal discharge and was sent for an ultrasound scan and a CT scan at the Charter Medical Centre later that year. The scans showed a thickened endometrium (or lining of the uterus) of 14mm. In postmenopausal women, a thickened endometrium is a risk factor in the development of cancer, and Ms Desmond was immediately referred to the gynaecological clinic at the Mater Hospital, where Dr William Boyd arranged for her to undergo a hysteroscopy.
The inquest heard that nine months elapsed after the 2007 scans before Ms Desmond received the hysteroscopy and biopsy as an outpatient at the Mater Hospital’s Gynaecological clinic. Her son Stephen, who regularly accompanied his mother to the hospital for tests, told the inquest that he had called the Mater a number of times to request the test, which was performed by Dr Moses Abe, a fourth-year specialist registrar under the supervision of consultant gynaecologist Dr William Boyd.
Dr Abe was unable to obtain a sample of tissue for biopsy. His medical notes indicated that he found the endometrium (or lining of the uterus) to be atrophic, and he discharged Ms Desmond from the gynaecological clinic. The inquest heard that Dr Abe’s finding of an ultra-thin endometrium did not correspond to the finding of the 2007 scans showing a thickening of the endometrium, though Dr Abe and Dr Boyd both told the inquest that the hysteroscopy was the “gold standard” which overrode the results of the scans.
Following the hysteroscopy, there was no further communication between the consultant and his junior doctor. Dr Boyd told the coroner it was not Dr Abe’s duty to report to him, and that any further interaction with Dr Abe would have been unnecessary, as Dr Abe was an experienced doctor and was required to be allowed to work on occasion without supervision.
Coroner Dr Brian Farrell called his own expert witnesses, including consultant radiologist Dr Arthur Grey and consultant gynaecologist Dr John Price of Belfast’s Musgrave Park Hospital. Dr Price told the inquest that negative findings from a hysteroscopy did not exclude cancer and that there were other options for dealing with tests that produced conflicting results, as in Ms Desmond’s case. One option was to conduct a review of the results with the medical team. Another was to proceed from an outpatient pipelle hysteroscopy to a D&C hysteroscopy under general anaesthetic to try to obtain a tissue sample for a biopsy. If a D&C hysteroscopy provided no tissue sample, the hospital could continue to an MRI scan, which Dr Price described as the gold standard.
Following her discharge from the Mater’s Gynaecological clinic, Ms Desmond continued to experience the same symptoms, and was referred to the Gastroenterology clinic, where she received a CT Colonogram in June 2009. The Mater Hospital found the scan to be normal, and Ms Desmond was diagnosed with Irritable Bowel Syndrome.
Dr Price told the court that he had asked Dr Gray to re-examine the 2007 scans and the 2009 CT Colonogram. Dr Gray said that the 2007 scans showed evidence of organ-confined pathology of unknown nature, and that the 2009 CT Colonogram showed evidence of small amounts of metastatic disease in the uterine region. Dr Price told the court it was likely that Ms Desmond already had early-stage endometrial cancer when she first presented at the Mater Hospital.
Questioned about the 2009 scan, Mater radiologist Dr Michelle McNicolas told the court that she did not dispute that the 2009 CT scan showed evidence of cancer in the uterine region. She said her concern at the time was to check the scan for colon-related problems. She told the court that if the same scan appeared before her next week, based on the clinical information presented to her, she highly doubted she would spot the uterine cancer.
In 2010 Ms Desmond returned to the Mater Gynaecological Clinic with vaginal bleeding where a hysteroscopy and biopsy followed by a scan showed that she had advanced stage 3 uterine cancer. She received chemotherapy and a subsequent scan showed an improvement in her condition, but she was by then in palliative care. She was re-admitted to the Mater Hospital in late August of 2011 and died five days later of a pulmonary saddle embolism, a complication of advanced uterine cancer.
Giving his decision, the coroner said that it was better for cancer to be discovered early. He said that his remit was to identify what he termed “risk factors” where improvements in care could prevent unnecessary deaths. He pointed out that a review of the treatment of Ms Desmond following the different results of the 2007 scans and the 2008 hysteroscopy could have presented an opportunity for earlier intervention. Dr Farrell said the 2009 CT scan, which showed the uterine cancer, also presented an opportunity for earlier intervention though John Gleeson, solicitor for the Mater Hospital had disputed that the evidence allowed for this conclusion.
“The very first tests could have produced an early diagnosis, but instead I feel that my mother was bounced around the Mater Hospital from pillar to post. She had 28 outpatient visits and ten procedures in different clinics before the cancer was diagnosed. Money is being squandered on unnecessary investigations”.
Following the conclusion of the inquest, Mr Desmond told Village that the sequence of events shed light on the reasons that women are misdiagnosed with irritable bowel sydrome rather than uterine or ovarian cancer. “What happened to my mother was a case in point”, he told Village. “She actually went first to the Gynaecological Clinic at the Mater Hospital, and was discharged after the hysteroscopy. When she went to the Gastroenterology Clinic, the CT Colonoscopy actually showed evidence of cancer in the uterus and surrounding areas, but they didn’t check the uterine area because they were focused on the colon and other organs.”
Mr. Desmond said that he felt the evidence given to the inquest raised broader issues about continuity of care and public safety. “People talk about the expense of treatment,” he said, “but my mother’s treatment illustrates the amount of money that is wasted because of a failure to diagnose diseases at an early stage. The very first tests could have produced an early diagnosis, but instead I feel that my mother was bounced around the Mater Hospital from pillar to post. She had 28 outpatient visits and ten procedures in different clinics before the cancer was diagnosed. Money is being squandered on unnecessary investigations”.
He said that the issues raised in the case deserved further investigation. “How many people have abnormal scans and don’t get biopsies or are discharged without getting a biopsy or an MRI?”, he asked. “I also wonder how many scans are not being read properly”.
Mr Desmond is now in the process of establishing the Maureen Desmond foundation in honour of his mother. The foundation, he said, will provide an ongoing summary of his fight for justice for his late mother, and will raise awareness about gynaecological cancers in Ireland. He said he hoped that the work would prompt Gastroenterologists to refer women experiencing abdominal pain and cramps to test for uterine or ovarian cancers “before diagnosing nebulous Irritable Bowel Syndrome”.
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Angels of Hope Charity N.I.