by Ronan Lynch
Although Belfast woman Una Crudden is terminally ill with cancer, she’s using her time to raise awareness that ovarian cancer is commonly misdiagnosed as irritable bowel syndrome. When she started suffering stomach pains in 2010 at the age of 56, Mrs. Crudden’s GP diagnosed irritable bowel syndrome. Returning to the GP three months later, she was referred to a gynaecologist, and further tests established that she had ovarian cancer. Although the diagnosis was late, it allowed Mrs. Crudden to receive treatment. Others were not so fortunate. Mrs. Crudden discovered that she was one of five women living in a four-mile radius who had been misdiagnosed with irritable bowel syndrome. She is the only one of the five still alive.
A case currently underway at Dublin Coroner’s Court may throw light on similar situations in the south, after a Dublin woman was diagnosed in 2009 with irritable bowel syndrome and returned to hospital a year later to find that she had inoperable stage 3 uterine cancer. The inquest, which holds its next session on August 29, is into the 2011 death of 74-year-old Dublin woman Maureen Desmond.
After suffering from vaginal discharge in 2007, Mrs. Desmond was referred to the Mater Hospital after scans at the Charter Medical Centre showed a thickened endometrium (or membrane of the uterus), which can indicate early stages of uterine cancer. A hysteroscopy in 2008 and a CT scan in 2009, both at the Mater Hospital, returned “normal” results, but a further hysteroscopy and scan in 2010 found that Mrs. Desmond had stage 3 cancer that had spread beyond the uterus and was inoperable.
Doctor told inquest hysteroscopy is “gold standard”
The inquest was requested by Mrs. Desmond’s son Stephen, a senior lecturer at Southampton Solent University who regularly travelled back to Dublin during his mother’s treatment to accompany her to the hospital. Mater Hospital consultant gynaecologist Dr. Bill Boyd, medical oncologist Prof. John McCaffery, general medical consultant Dr. Jack Lambert and histopathologist Dr. Ciara Barrett appeared as witnesses on the opening day of the inquest in September last year. Dr. Boyd told the court that Mrs. Desmond was first referred to him after she attended the Charter Medical Centre in Smithfield, Dublin in November 2007 with abdominal discomfort and vaginal discharge. An Ultrasound and CT scan test at the centre showed a 14mm thickening of the endometrium (the membrane of the uterus). Dr. Boyd said he first saw Mrs. Desmond in April 2008, when he organized for her to undergo a hysteroscopy and D&C. Dr. Boyd told the court that the hysteroscopy and D&C was performed in August 2008, and the result was deemed normal. No sample was obtained.
Dr. Boyd said that the hysteroscopy had been performed by Dr. Moses Abe, as he was himself not present that day. The notes of Dr. Moses indicated that a pipelle suction curette had been attempted, but no sample had been taken due to an “atrophic” or ultra thin cavity. Dr. Boyd said that it was not an infrequent occurrence for a hysteroscopy to contradict CT scans, which he said can “overread” the evidence. Dr. Boyd said that a hysteroscopy where the sight of both ostea (openings to the fallopian tubes) is obtained is the “gold standard”, and overrides the results of CT and ultrasound scans.
Dr. Boyd read for the inquest the notes of Dr. Moses, which he described as “very well-written and very exact.” According to Dr. Boyd, Dr. Moses Abe recorded “Left ostia, seen, right ostia seen, NAD [no abnormality detected], no lesion.” The procedure did not obtain a tissue sample for biopsy, as the patient’s endometrium was “atrophic.” Dr. Moses Abe discharged Mrs. Desmond from the Mater following the examination. The coroner asked Dr. Boyd if he had interacted with Dr. Moses Abe following the junior doctor’s decision to discharge Mrs. Desmond, and Dr. Boyd replied that he had not. He said that any further interaction with Dr. Moses would have been inappropriate, as Dr. Moses was an experienced doctor, and was required to be allowed to work on occasion without supervision.
Independent report raises issues around waiting times and hysteroscopy
Mr. Desmond told the court that he had obtained an independent medical report from Dr. John Monaghan, a consultant gynaecological oncologist based in Newcastle, England and author of textbook Bonney’s Gynaecological Surgery, which raised questions about the events leading up to, during and after the hysteroscopy performed on Mrs. Desmond in 2008. Mr. Desmond requested the coroner to call Dr. Monaghan as a witness.
Village has seen the report by Dr. Monaghan, who is of the view that there had been a clear breach of duty in Mrs. Desmond’s care. His report states that the nine month delay before the first biopsy was unacceptable and negligent. According to Dr. Monaghan, the initial pipelle procedure may have been acceptable had the junior doctor been supervised and if the findings had been checked, but he found the failure to follow the unsuccessful first pipelle biopsy with a full hysteroscopy and D&C to be substandard and negligent. He also stated that it was unacceptable to presume that because no sample has been obtained that the endometrium must be atrophic, and said that the discharge of Mrs. Desmond without any review of the case or the patient was also substandard and negligent.
Mr. Desmond told the coroner that the fundamental issue was whether it was reasonable for the Dr. Moses to conclude that he had obtained no tissue sample on the basis of the endometrium being ultra thin, in spite of the scans showing a thickened endometrium. He told the court that he had been present with his mother on the day of the initial hysteroscopy in 2008. Dr. Moses Abe took Mrs. Desmond into a cubicle in the day surgery ward, while Mr. Desmond sat outside. Mr. Desmond told the court that there was a tall window at the rear of the cubicle, and that he heard the nurse tell Dr. Moses that they could not see the screen because of the light, and heard her ask if she should draw the blinds. The doctor said no. Mr. Desmond said he was aware that the procedure was very difficult for the doctor and his mother, as his mother was in a lot of discomfort and was shouting in pain. Following the examination, Dr. Moses discharged Mrs. Desmond from the hospital. Dr. Boyd told the court that Dr. Moses was an experienced professional and would have known how to use the screen properly. The coroner told the court that he would consider calling Dr. Moses to give evidence.
Patient was diagnosed with irritable bowel syndrome, later diagnosed with stage 3 cancer
Mr. Desmond told the inquest that after being discharged from the Gynaecology clinic with a clean bill of health, his mother continued to experience symptoms of abdominal discomfort, vaginal discharge and illness, and attended several different departments of the Mater Hospital for testing. He said that the Diabetic clinic could not explain his mother’s continued vaginal discharges, and in November 2008 recommended that she be placed on one antibiotic per day for life. In June 2009, the Gastroenterology unit conducted a CT colonoscopy on Mrs. Desmond because she continued to experience abdominal discomfort, and found the results to be normal. She was diagnosed with irritable bowel syndrome and prescribed a lifelong programme of Buscopan medication.
In July 2010, Mrs. Desmond experienced vaginal bleeding and was re-admitted to the gynaecology department, where the results of a hysteroscopy and D&C performed under general anaesthetic established that she had stage 3 uterine cancer. A follow-up test found that the cancer had spread beyond the uterus. Mrs. Desmond was treated with chemotherapy but suffered an adverse reaction including a small stroke, and an infection in her chemotherapy port resulted in an extended period of hospitalisation. She was discharged into palliative care in April 2011. She died in July 2011 after being admitted to the Mater Hospital through the A&E unit after suffering from shortness of breath, where she died five days later. The coroner’s postmortem noted that Mrs. Desmond had died from a pulmonary embolus (a failure of the lungs due to a blood clot) secondary to metastatic endometrial adenocarcinoma.
Mr. Desmond also raised the issue of the care of his mother in her final days in early September 2011, after she had been admitted to the Mater Hospital through A&E, suffering from shortness of breath. She was placed under the care of consultant Dr. Jack Lambert and his team. After four days, staff diagnosed Mrs. Desmond as suffering from an embolism and booked her in for a CT Scan and a CT Pulmonary Angiogram the following week.
Mr. Desmond told the inquest that on the day before she died, he became alarmed at the amount of morphine and codeine being given to his mother and said that he had subsequently discovered these levels were expressly forbidden in the case of someone suffering acute breathing problems. Mrs. Desmond died on the morning of 4 September while being transferred to the Special Care Unit. Mr. Desmond said that the morphine and codeine levels recorded in his mother’s body in the autopsy report were identical to levels found to be lethal in a young Australian woman who was experiencing a chest infection. The Mater histopathologist Dr. Ciara Barrett agreed to amend her autopsy report to include elevated morphine and codeine levels as a secondary cause of death.
Next session of inquest on August 29
At a subsequent organisational mentions at the Coroner’s Court in April 2014 and July 2014, the coroner indicated that he would not call Dr. Monaghan as a witness but would circulate Dr. Monaghan’s report to the other witnesses. He said he would call his own expert witnesses in regard to the initial CT scan from November 2007 and the CT Colonoscopy scan from 2009, and in regard to the hysteroscopy and D&C procedure. The coroner’s expert witnesses will appear at the next sitting of the inquest on Friday 29 August. Dr. Moses Abe, who now works in Victoria, Australia, will appear as a witness via Skype late in September. The coroner said that he will produce a separate expert report into Mrs. Desmond’s final days at the Mater Hospital.