Dublin Coroner returns verdict of medical misadventure in Mater Hospital case.
By Rónán Lynch
another death from uterine cancer misdiagnosed as cramps 
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”.
Previous coverage:
Inquest continues into death of Dublin woman at the Mater Hospital
Angels of Hope Charity N.I.
Angels of Hope Charity
by Ronan Lynch Friday - Oct 10, 2014
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
.