Regulation & Quality Improvement Authority

Regulation & Quality Improvement Authority RQIA Governance Review of the Northern Ireland Breast Screening Programme Quality Improvement Review 2/06

Contents Foreword Page Executive Summary 1. Introduction 1 2. Background 2 3. The Review 5 4. Context 6 4.1 Northern Ireland Breast Screening Programme 6 4.2 The Screening Process 6 4.3 Accountability structures 7 4.4 The Regional Advisory Group 8 4.5 Key roles identified within the structures 8 4.6 Clinical and QA Guidelines 8 5 Key Findings 10 5.1 Workforce issues and their impact on the service 11 5.1.14 Review panel analysis 15 5.1.16 Recommendations 16 5.2 Management of competency issues (i) 17 March 2004-November 2004 5.2.26 Review panel analysis 25 5.2.32 Recommendations 28 5.3 Management of competency issues (ii) 29 November 2004-October 2005 5.3.6 Review panel analysis 31 5.3.10 Recommendations 32 5.4 The Recruitment and Selection Process 33 5.4.12 Review panel analysis 35 5.4.19 Recommendations 38 5.5 Clinical and QA Guidelines 39 5.5.23 Review panel analysis 46 5.5.26 Recommendations 47

6 Conclusion and Recommendations 48 7 Acknowledgements 52 8 References 53 9 Appendices 54 Appendix 1 Terms of reference as outlined by DHSSPS 55 Appendix 2 Timescales of the review process 57 Appendix 3 Review panel members 58 Appendix 4 List of main stakeholders 59 Appendix 5 Regional Advisory Structure 60 Appendix 6 Employer Accountability Structure 61 Appendix 7 Serious Adverse Incident Report 62 10 List of tables 64 Table 1 Employment by Hospitals across HPSS Board Areas Table 2 Radiology Medical Staffing from 1999 2005 Table 3 Number of radiographers employed in the HPSS (1999 2005) Table 4 Example of interview scores awarded and comments 11 Glossary of terms 65

Foreword The Genesis of the Report The Quality Improvement and Regulation Order [2003] Northern Ireland places responsibility upon the Regulation and Quality Improvement Authority to carry out functions to support improvement in the quality and the Regulation of services. The functions of carrying out investigations into, conducting reviews of and making reports on, the management, provision or quality of the health and personal social services, for which statutory bodies have responsibility, are undertaken with the general duty of encouraging improvement in the quality of services. The Incident Reported This Report sets out the findings and recommendations for improvement following a serious adverse incident notification. The adverse incident was notified in the Breast Screening Service where it was noticed that the protocols for diagnosis of potential Breast Cancers, in some women, were not undertaken in accordance with recognised standards. The adverse effect of the serious clinical incident was minimised by the actions of staff who, having recognised failings in the standards of service, notified their concerns in accordance with good clinical practice and sound clinical governance. It is this standard of good governance and clinical practice which characterises health services, which the public has a right to expect, which must be encouraged and which must help to give confidence in screening services to the wider public. Public Awareness Breast Screening is crucial to improving the health outcome and well being of women. The media interest which surrounds the publication of this report should take the opportunity to encourage women to use the Breast Screening Service and to read this report to restore public confidence in the standards of the service where the recommendations for improvements in the service and its Quality Assurance systems will be monitored by Regulation and Quality Improvement Authority. The Women Affected The women who were recalled for further assessment at Breast Screening following the notification of the adverse incident have suffered serious and varying degrees of anxiety and distress. The service has offered a sincere apology and an acknowledgement of the difficulties experienced by the women and their families. For those women whose recall revealed a diagnosis of cancer there is the additional fear of whether or not the delay in diagnosis has had a significant

clinical effect. Our thoughts are with those women and their families who are now on a path of care and treatment for the Breast Cancer and who can expect the best standards of care for the optimum outcome for their health and well being. Those affected may take some small consolation from the recommendations in this report which will help reduce the risk of such an adverse incident arising again. Stella Burnside Chief Executive Regulation and Quality Improvement Authority

Executive Summary This Regulation and Quality Improvement Authority report follows a request from the Department of Health, Social Services and Public Safety, to undertake a Clinical and Social Care Governance review of the Northern Ireland Breast Screening Programme. The review was prompted by concerns raised by clinical staff in the Antrim Area Hospital about the clinical judgement of a single consultant radiologist. These concerns were the subject of a serious adverse incident report to the DHSSPS. The report follows a clinical review of the Breast Imaging work of the identified consultant, led by Dr Robin Wilson Consultant Radiologist, Nottingham Breast Institute. The terms of reference for the report are as follows: 1. To investigate the circumstances that contributed to the need to reassess 44 patients at Antrim Area Hospital, following referral from the Breast Screening Programme. 2. To determine whether clinical guidelines for Breast Screening Assessment are in place and being applied in Northern Ireland. 3. To determine whether the Quality Assurance Guidelines for Breast Screening radiology are in place and being followed in Northern Ireland. 4. To investigate any other governance issues pertaining to this matter. The RQIA agreed a methodology for the investigation and identified an independent, expert review panel. Background The report examines the circumstances and key events that led to the recall of 44 women at Antrim Area Hospital, following referral from the Breast Screening Programme, over the period January 2004 to October 2005. The Northern Ireland Breast Screening Service was set up in 1988 at the same time as the National Health Service Breast Screening Programme, with screening/assessment services provided in 4 static breast units supported by 3 associated mobile screening units. The service is supported and monitored by a Regional Advisory Group that was set up within the National Health Service Breast Screening Programme Guidelines. These guidelines not only determine i

advisory structures but also set out best practice guidelines on all aspects of the provision of breast screening services. One of the static screening units is at Antrim Area Hospital which is part of the United Hospitals Trust. This unit provides breast screening, assessment and breast symptomatic services for patients in the Northern Health and Social Services Board. The consultant whose work is at the centre of this review was employed as a general radiologist doing a small number of breast radiology sessions in Altnagelvin Hospitals Trust since 1995. The consultant was recruited to Antrim Area Hospital from July 2003 as part of a team of 3 radiologists, all of whom were undertaking sessions in the breast unit. From December 2003 he worked as the sole breast radiologist in Antrim Area Hospital within a multi-disciplinary team. Although this review deals with the incident notified to the DHSSPS on 7 th November 2005, it was necessary for the panel to review a related incident in March 2004. In March 2004 film reading radiographers raised concerns about the clinical judgement of the identified consultant in relation to the management of 5 women recalled for breast screening assessment. The concerns centre on a three month period from January 2004 when the identified consultant had been working as the sole breast radiologist. There were no concerns expressed about his work prior to January 2004 when he had worked in the Breast Unit with an experienced consultant breast radiologist. In order to identify the lessons that must be learned from this critical incident and to make recommendations for the wider health and social services in Northern Ireland, this review has identified four important parameters throughout the period January 2004 to October 2005 into which causes for concern can be grouped. 1. How workforce issues impacted on the service. 2. How the identified consultant radiologist s competency and clinical performance were managed in the Trusts in which he worked. 3. How the selection and recruitment process for medical consultants impacted on the circumstances leading to this incident. 4. How the use of clinical and QA guidelines influenced the quality and provision of breast screening services. The findings of the review team illustrate that within each of these parameters there were opportunities for senior medical and management staff to take actions that could have led to a different outcome. A number of concerns are raised from which lessons must be learned so that the risk of recurrence is minimised. ii

Workforce issues and their impact on the service A chronic shortage of radiology and non radiology film readers contributed to the circumstances which led to the identified consultant working in a degree of isolation, without peer support, at Antrim Area Hospital from January 2004 to October 2004 except for a short period of time in April June 2004. These workforce problems had been highlighted in numerous letters and meetings in relation to radiologist and radiography workforce in the Northern Ireland Breast Screening Programme. Reports into other breast screening services across the United Kingdom show similar workforce shortages in radiology and radiography. There would appear to have been little progress made to resolve these issues. Antrim Area Hospital undertook proactive steps to recruit a radiologist for the breast screening unit which extended beyond Northern Ireland, with no success. It is also clear that substantial investment had been made by DHSSPS to increase the numbers of staff working within radiological services, however this did not specifically focus on the workforce issues in the breast screening services despite the ongoing concerns raised through the Regional Advisory group, the Northern Health and Social Services Board or Antrim Area Hospital. The Northern Ireland Breast Screening Programme remains understaffed in the key areas of film reading, assessment and symptomatic breast radiology. The review panel feel that the workforce issues outlined appear to have had an influence on the circumstances leading to the incident under review. Management of competency issues (i) March 2004 - November 2004 During this period, issues were raised about the clinical competence of the identified consultant. Formal procedures had been considered by Antrim Area Hospital, however they stated that they felt this was not the appropriate vehicle to address the concerns raised at this time and subsequently favoured a more supportive approach to the consultant. This supportive approach involved considerable management of the issues by the Regional QA Director who did not in fact have any line management responsibility for the identified consultant. Senior Managers at Antrim Area Hospital stated that this approach was taken to protect the working relationships within the breast unit team and sustain the service, which was described by the Trust as being under threat. However, at no time did anyone from the Trust senior management team or the regional QA Director discuss the concerns about clinical competence with the identified consultant. An educational programme was developed by the senior management team in Antrim Area Hospital for the identified consultant, which included visits to a training centre in Glasgow, supervision at screening sessions at the Eastern Health and Social Services Board screening centre and supervision for a 3 month period at clinics in the breast screening unit in Antrim Area Hospital. However, a formal assessment of the consultant s competence was not carried iii

out at any time during this programme. This appeared to run contrary to the plans that had been agreed by the senior management team in Antrim Area Hospital. A planned attendance at the international training day, did not take place until June 2005 which was 7 months after the identified consultant left his post in Antrim Area Hospital. The review panel is in agreement with the Wilson Report which highlights that the periods of retraining and supervision provided in 2004 appear not to have prevented this radiologist from providing substandard care. The review panel suggest that the efficacy of the training programme had not been formally assessed. This could have been carried out by an exclusive audit of the identified consultant s own work. The audit of the cases seen between April to June 2004 included work which had been supervised by the regional QA Director and another experienced breast radiologist. No further audit of the consultant s own work was carried out from July to October 2004, a time when the identified consultant worked as the sole radiologist in Antrim Area Hospital. The reason cited for this was because the consultant had been appointed to another job in the Belfast City Hospital. It is the opinion of the review panel that the QA Director s advice to Antrim Area Hospital may have been flawed. The chief Executive of the Antrim Area Hospital stated that he placed considerable weight on the advice of the regional QA Director. There is little evidence that the concerns about the identified consultant s laissez faire approach, was being managed by Antrim Area Hospital throughout this period. It would also appear that the way in which this was managed by the Trust was to state that they reduced the workload of the consultant at clinics to match the work rate of the identified consultant rather than the requirements of the service. It would also appear that the Clinical Director abdicated his line management responsibilities in relation to the identified consultant s competence and attitudinal failings. The review panel also conclude that he failed to support the identified consultant in managing his workload. These actions led the review team to conclude that throughout this time there was no focused management or leadership from the Clinical Director of Radiology who made an assumption that the regional QA Director was dealing with the competency issues. This lack of focused management or leadership provides a key indicator of the future performance of the identified consultant. The review panel are concerned that management at the most senior level within Antrim Area Hospital failed to recognise the significant risks being taken in continuing to provide breast screening services where there was an element of doubt about the competence of a consultant radiologist. In the management of the incident in March 2004 they failed to: Be explicit with the consultant about the nature of the issues raised about his clinical judgement. iv

Follow good governance principles for dealing with failing competence and performance. Implement the agreed action plan in relation to the management of the identified consultant. Management of competency issues (ii) November 2004-October 2005 In October 2005 clinical staff again raised concerns about the clinical competence of the identified consultant. On this occasion the review panel can conclude that the action taken by the Trust and Northern Health and Social Services Board on 7 th November 2005 was appropriate and in accordance with NHS Breast Screening Programme Guidelines for Managing Incidents in the Breast Screening Programme. In addition to these actions the United Hospitals Trust also notified the DHSSPS of the incident through the Serious Adverse Incident Procedure. It was notable that in addressing the issues highlighted under this adverse incident the Trusts, Boards and Regional Advisory Group in co-operation with the DHSSPS acted swiftly to review the cases under the management of the identified consultant. The speed of this review was unprecedented and should be commended as a model of good practice for similar incidents in the future. The review panel agrees with the comments on lessons learned from using this methodology. How patients are informed without causing anxiety must be noted for future reviews and investigations. The review panel note that despite concerns expressed by DHSSPS about the payment to the identified consultant for his locum work, which considerably exceeded the sessions worked, the Trust continued with this payment. This was despite the fact that the Trust stated that they continued to reduce clinic throughput to match the work rate of the consultant and not the requirements of the service. It would also appear that in directly approaching the identified consultant about undertaking this locum work, at an enhanced pay rate, management at Antrim Area Hospital failed to be open and transparent in offering locum work to other consultants who may have been interested in providing locum cover. The Review Panel acknowledge that the principle reason for the incidents was that the identified consultant did not fulfil his professional responsibilities in a manner which the Trust had a right to expect from an accredited radiologist. However, the availability of expert advice on which the Trust placed considerable weight, from the regional QA director did not replace the singular accountability of the employing authority. v

The Recruitment and Selection Process The review panel accepts that there is a fine balance between disclosing knowledge of a candidate at interview and the impact on the reputation of the employing body, however, this should in no way negate the view that the welfare and safety of patients is paramount. Belfast City Hospital senior management staff stated that they would expect any interview panel member to disclose information about a candidate s professional competence and that this information may influence the outcome of the interview. Although there appears to have been no formal mechanism for the transfer of such information to other organisations, it is notable that in the revised procedures for handling concerns about doctors and dentists HSS(TC8) 6/2005 (new procedures which were introduced in June 2005) there is specific guidance on sharing information with other organisations to promote patient safety. The Neale Enquiry (2004) states that all previous contacts between applicant and interviewers should be disclosed and recorded. The review panel are concerned at the inconsistent approach taken by the interview panel at the time of the appointment of the identified consultant to the Belfast City Hospital. The ratings awarded to the candidate appeared to be inconsistent with the comments made by panel members. Concerns also arise from the number of panel members who made changes to the ratings given to the candidate. In at least one example these changes brought the candidate s scoring up to the minimum level required for appointment. The job specification and the interview transcripts highlight the need for increased focus on non-clinical competencies for consultant posts. The job description for the post advertised shows little emphasis on the concepts of leadership, communication and team working which are increasingly important attributes in modern medical practice. The review panel considered that the reference provided by the Clinical Director of Radiology in Antrim Area Hospital (dated 31 st July 2004), in respect of the identified consultant may have been misleading given the ongoing professional competency issues. In 2001 the General Medical Council issued specific guidance on providing a reference. It stated that you must provide only honest and justifiable comments when giving references for or writing reports about colleagues. When providing references you must include all relevant information which has any bearing on your colleague s competence, performance and conduct. It is concerning that the Clinical Director of Radiology in Antrim Area Hospital reported that although he provided a reference within the time frames outlined he felt that the reference provided was accurate. He stated that the responsibility for informing the panel of the ongoing competency issues of the identified consultant was with the QA Director who had provided support and advice during the re- vi

training programme. This QA Director was also a member of the interview panel. The review panel are concerned that the view of Clinical Director for Radiology in Antrim Area Hospital appears to abdicate his professional and managerial responsibilities. He provided a reference for a consultant whom he knew to be the subject of an ongoing investigation and assessment about his clinical work. It would appear to reflect the approach of senior management staff at the Trust that responsibility lay with the regional QA Director, whose role should have been primarily advisory. It continues to highlight the need for clarity of roles and responsibilities in the accountability and employment structures for the Northern Ireland Breast Screening Programme. The HPSS procedure for the appointment of medical staff does not make provision for any current, previous, pending inquiry or investigation about their professional competence. The review panel recommend that application forms should contain a declaration (that all information is correct to the best of the applicant s knowledge and belief and any matter, professional or personal unresolved or pending that might undermine the applicant s standing, or cause embarrassment to the NHS, should be declared) by a confidential side letter to the chairman of the interview panel. Clinical and QA Guidelines All Boards and Trusts involved in this review indicated in their submissions that National Clinical and QA standards were in use within the services that they provided. It would appear that Antrim Area Hospital did not rigorously adhere to a number of these guidelines. These included: British Association of Surgical Oncologists Guidelines for the management of symptomatic breast disease NHS Breast Screening Programme Guidelines for Breast Screening Assessment and, Managing incidents in the Breast Screening Programme (March 2004) Not only was it clear that the identified consultant appeared not to follow guidelines rigorously; it appeared that there was no mechanism within the Trust to ensure that these guidelines were adhered to. For example no action was taken by the Trust to ensure that there was a radiologist at the multi-disciplinary meeting. It would also appear that to a large extent the Annual Statistical Reports compiled by the Regional QA Director would focus more on the overall performance of the service rather than its quality assurance. The review panel were concerned that the QA audit visit undertaken in October 2003 and published in August 2004 used the Scottish Board Standards. The Northern Ireland programme works to the NHS Breast Screening Programme standards. It is notable that the chairperson of the Regional Advisory Group has vii

stated that the next QA visit scheduled for 2006 will be undertaken by the Nottingham Training Centre which will assess the Northern Ireland Breast Screening Programme against the NHS Breast Screening Programme standards. Given that this QA visit concentrates on the performance of the service the review panel are of the view that the Northern Ireland Breast Screening Programme should also take account of the Quality Standards for Health and Social Care published by the DHSSPS. viii

Recommendations Workforce issues and their impact on the service 1. DHSSPS, Boards, Trusts and Northern Ireland Medical and Dental Training Agency should actively promote post graduate radiology trainees to choose breast radiology as a sub-speciality. The DHSSPS should target a number of Specialist Registrar posts in radiology for the breast radiology sub-speciality in addition to those planned for other radiology practice or sub-speciality interest. This recommendation should also be applied in other vulnerable medical specialities. 2. DHSSPS, Boards and Trusts should actively promote the various models of service provision through a range of skill mix options as outlined by NHS Breast Screening Programme, the UK Department of Health and The Society of Radiographers. Skill mix options for the Northern Ireland Breast Screening Programme should be reflected in the Northern Ireland Workforce Development Strategy developed by the DHSSPS. 3. The viability and sustainability of the Breast Screening Programme in an area where there are on-going staff shortages, must be considered by DHSSPS, HSS Boards and Trusts within an agreed action plan based on the assessed risks and good governance. 4. Plans to further extend the upper eligible age range of routine invitation to Northern Ireland Breast Screening Programme to women aged 65-70 years, should be suspended until workforce issues have been satisfactorily resolved within the service to provide such capacity. Management of competency issues (i) March 2004 - November 2004 5. The Northern Ireland Breast Screening Programme should clarify with Trusts and Boards the role and accountability of the Regional QA Director and make explicit the responsibilities in the management of failing competence and underperformance of staff. 6. All Trusts should ensure that concerns about failing competence and/or performance of medical consultants should be dealt with under the recognised framework - Maintaining High Professional Standards in the Modern HPSS (November 2005) HSS(TC8) 6/2005. 7. Governance processes should be in place to ensure that when failing competence and medical underperformance is assessed, action ix

plans are developed with agreed timescales for implementation. Implementation should be subject to review and monitoring by Trusts with appropriate use of the National Clinical Assessment service. 8. The DHSSPS should further review and issue definitive guidance on the payment of incentives to consultant medical staff, ensuring that those staff are able to meet in full the requirements of their substantive contract and agreed work plan. 9. The DHSSPS should issue revised guidance on the recruitment and selection of locum consultant staff in Trusts/Boards. 10. All Trusts should ensure that annual consultant appraisals are implemented as a matter of urgency (including appraisal for locum consultant staff employed for more than three months). RQIA will undertake an improvement review of consultant appraisal and the role of Clinical Directors in managing medical performance across all Trusts in 2006/2007. Management of competency issues (ii) November 2004-October 2005 11. The results of the Wilson Report and the findings of this review identify grave concerns in professional competence which should be notified to the General Medical Council if this has not already been done. RQIA will review the governance processes within Belfast City Hospital as applied to this issue. 12. The RQIA will conduct a further detailed governance review of medical management and leadership in United Hospitals Trust (with particular emphasis on clinical directors) using HPSS Clinical and Social Care Governance Standards. The Recruitment and Selection Process 13. Trusts and employers must ensure that disclosure of information as part of the selection and recruitment processes for all grades of medical staff are in accordance with relevant legislation, good practice guidelines and professional regulatory requirements. The RQIA will require Antrim Area Hospital to demonstrate that due process is followed in the review of the matter of the reference provided, regarding the identified consultant s application to Belfast City Hospital. x

14. Trusts must take appropriate steps to ensure that interview panel members have up to date knowledge and skills in selection and recruitment processes. 15. Medical staff must adhere to General Medical Council Guidelines when providing references or reports about medical colleagues. 16. All documentation relating to selection and recruitment of medical staff should be reviewed to ensure that there is provision to question applicants about any professional or personal, unresolved or pending issue that might undermine the applicant s standing, or cause embarrassment to the NHS. An arrangement should be incorporated for a confidential declaration to be received by the interview panel chair. 17. Medical Managers and Human Resource departments should ensure that all job specifications for consultant medical staff and Clinical Directors clearly outline all relevant competency domains relating to the role. These should include clear descriptions of competency in leadership, communication and team working as relevant to the post. Clinical and QA Guidelines 18. Any future QA visits to breast screening units must be based on the NHS Breast Screening Programme guidelines and standards. These visits should also take account of the DHSSPS Quality Standards for Health and social care. 19. The recommendations of Northern Ireland Breast Screening Programme QA visits and all other quality reviews of the Northern Ireland Breast Screening Programme must be acted upon. It is the responsibility of the QA Director and QA Coordinator to ensure that these action plans are implemented within the agreed time frames through 6 monthly visits to breast screening units. 20. Whilst valuing the contributions of the entire multi-disciplinary team, all units should ensure that the screening assessment multidisciplinary team meeting cannot take place without the attendance of the breast radiologist, breast surgeon/clinician and pathologist and that symptomatic multi-disciplinary team meetings cannot take place without the above clinicians and an oncologist. xi

1 Introduction 1.1 On the 21 st November 2005 the Regulation and Quality Improvement Authority (RQIA) was asked by the Department of Health, Social Services and Public Safety (DHSSPS) to carry out a Clinical and Social Care Governance review of issues arising from the Northern Ireland Breast Screening Programme (Appendix 1). This review was prompted by concerns raised by clinical staff in Antrim Area Hospital about the clinical judgement and decision making of a particular consultant radiologist. These concerns were viewed by senior hospital staff and medical staff at the Northern Health and Social Services Board as serious adverse incidents and were reported to the DHSSPS under the serious incident reporting procedure. The findings of the RQIA governance review presented in this report are independent of the Wilson Report 1 - an extended clinical review of breast imagining work by the identified consultant. 1.2 The RQIA operates within the legislation of the Quality Improvement and Regulation Order (Northern Ireland) 2003 2. It is an independent, nondepartmental public body that has the responsibility for monitoring, inspecting and reviewing standards for health and social care across all sectors and keeping the DHSSPS informed of those standards. This Order places a statutory duty of quality upon Health and Personal Social Services (HPSS) organisations, determines the development of standards for care and for clinical and social care governance and requires the RQIA to encourage continuous improvement in the quality of care and services throughout all sectors in Northern Ireland. 1.3 Clinical and social care governance is described as a framework within which HPSS organisations can demonstrate their accountability for continuous improvement in the quality of services and for safeguarding high standards of care and treatment. 1.4 The events which are the subject of this review have been examined within the context of clinical and social care governance, the legislation as outlined above and within the terms of reference as determined by the DHSSPS. This report makes recommendations for learning and improvement in the Breast Screening Programme and the wider HPSS in Northern Ireland. 1 Wilson (2006) Report on a Review of Breast Imaging at Altnagelvin Hospital, Belfast City Hospital and Antrim Area Hospital, September 2002 November 2005 2 Health and Personal Social Services (Quality, Improvement and Regulation) (Northern Ireland) Order 2003 1

2 Background 2.1 The concerns raised by clinical staff working in the breast screening unit in Antrim Area Hospital in early October 2005 resulted in the issuing of a critical incident report on the 18th October 2005. This led to a decision on the 31 st October 2005 to initiate a review of breast screening assessment cases that had been carried out in that unit by an individual consultant radiologist. The review identified cases of cancer that would have been overlooked had other clinical staff not intervened at that time to ensure that correct procedures were undertaken. This prompted a further review of the breast imaging work of the identified consultant radiologist, led by Dr R Wilson on the 15 th November 2005. A total of 519 breast screening assessment cases that were seen at Antrim Area Hospital between July 2004 and November 2005 were reviewed. 2.2 The identified consultant who was under investigation in the Wilson Report had carried out breast imaging and general radiology services in three acute hospitals in Northern Ireland since September 2002. These hospitals are sited in three different HPSS Board areas, as outlined in Table 1. Hospital HPSS Board Time in substantive consultant post Altnagelvin WHSSB Jan 1995 Hospital July 2003 Antrim Area NHSSB Aug 2003 Time in locum post Sept 2002 Hospital Oct 2004 July 2003 Belfast City EHSSB Nov 2004 to Hospital date Table 1: Employment by Hospitals across HPSS Board Areas Dec 2004 Oct 2005 2.3 The findings of the Wilson Report identified serious failure in standards of clinical medical practice in breast screening assessment. The Wilson Report states that of the 519 breast screening assessment cases reviewed on 15 th November 2005 there were 39 cases recommended for urgent reassessment because of concerns that appropriate investigations had not been carried out. These 39 cases were in addition to the 5 cases identified on 31 st October 2005 in an audit carried out by the regional QA Director when concerns were initially highlighted. Therefore a total of 44 cases were recalled to Antrim Area Hospital. 2.4 The Wilson Report states that: In the extended review carried out in the Wilson Report, 77 of the 963 assessment cases were reviewed and identified as requiring 2

reassessment (Belfast City Hospital 19; Antrim Area Hospital: 58). Eight women have been diagnosed to have breast cancer as a result of the screening assessment review and all have received initial treatment (Belfast City Hospital 1; Antrim Area Hospital 7). Two women declined reassessment and one woman declined to have a breast biopsy. 2.5 Wilson Reports that: Three hundred and fifty five of the 6640 symptomatic patients reviewed were identified as requiring reassessment (Belfast City Hospital 104; Antrim Area Hospital 251). Six of these have been diagnosed to have breast cancer and are being treated (Belfast city Hospital 1; Antrim Area Hospital 5). 2.6 The decision to undertake an extended review of the consultant s breast imaging work in the three hospitals involved was made at a meeting with representatives from the hospitals, HPSS Boards and DHSSPS on the 19 th November 2005. The identified consultant radiologist was suspended from clinical practice pending Belfast City Hospital disciplinary procedures which would be determined by the outcome of the Wilson Report. 2.7 Further to the Wilson Report the DHSSPS Minister, Shaun Woodward requested that an independent governance investigation be undertaken by RQIA into the circumstances that resulted in 44 patients being recalled for further breast cancer assessment. 2.8 The terms of reference for this investigation were set out by the DHSSPS as follows: 1. To investigate the circumstances that contributed to the need to reassess 44 patients at Antrim Area Hospital, following referral from the Breast Screening Programme. 2. To determine whether clinical guidelines for Breast Screening Assessment are in place and being applied in Northern Ireland. 3. To determine whether the Quality Assurance Guidelines for Breast Screening radiology are in place and being followed in Northern Ireland. 4. To investigate any other governance issues pertaining to this matter. 2.9 The RQIA acknowledge that as a result of the incident there is a requirement to ensure that public confidence is restored in the Breast Screening Programme. This report will include recommendations and 3

follow-up monitoring on the actions of Boards and Trusts in respect of these recommendations. 4

3 The Review 3.1 The RQIA agreed with the DHSSPS to undertake the review as a matter of urgency and provide a report to the DHSSPS by the end of March 2006. Details of the timescales for each aspect of the review process are shown in Appendix 2. 3.2 The RQIA agreed a methodology for the investigation and identified an independent, expert review panel. 3.3 A review panel was formed with membership that included service user representation and NHS staff with expertise in the areas of breast screening radiology, breast screening quality assurance, public health and human resources management (Appendix 3). 3.4 A meeting was held on 1 st December 2005 with the relevant organisations to provide details of the review methodology and timescales. 3.5 The review panel s findings and recommendations are informed by all documentary evidence that was collected and analysed from relevant stakeholders using a governance pro-forma based on the terms of reference. Follow-up interviews were conducted with relevant HPSS and DHSSPS staff to complete the investigation (Appendix 4). 3.6 Draft copies of the review panel s findings and recommendations were forwarded to the organisations reviewed for comment on factual accuracy. 5

4 Context 4.1 The Northern Ireland Breast Screening Programme Breast cancer is the most common form of cancer in women, both in Northern Ireland and the developed world. Screening for breast cancer by mammography has been shown to reduce the death rate from breast cancer by up to one-third among women aged 50-69 years through early diagnosis. The Northern Ireland Breast Screening Programme was set up in 1988. It provides screening/assessment services in 4 static area screening units and is supported by 3 associated mobile screening units. The aim of the Northern Ireland Breast Screening Programme is to invite all eligible women aged 50-64 years to attend a free breast screening appointment once every 3 years. Approximately 42,021 women across Northern Ireland are invited for breast screening each year. The annual Analysis of Statistical and QA information 3 reports show that over the past five years an average number of 72% of those who were invited to attend accepted the invitation. Women over 64 years are also encouraged to self-refer to this screening programme. The DHSSPS Priorities for Action 2003/04 4 recommended that the Northern Ireland Breast Screening Programme should extend the upper eligible age range of routine invitation to include women aged 65-70 by March 2006. 4.2 The Screening Process The first stage of the screening is mammography (a low radiation x-ray of the breasts) which although not a definite, diagnostic test in itself is the most reliable way of detecting early breast cancer. It allows a radiologist or film reader to identify whether a woman s mammogram is satisfactory or requiring further assessment. If a mammogram result is satisfactory, the woman is returned to the routine recall system and will be invited for another screening test 3 years later. Where there is a question over whether the x-ray film is normal the woman will be recalled for assessment. Assessment may involve procedures beyond those undertaken at the first appointment including further x-rays and/or clinical examination, ultrasound, removal of a small amount of tissue or cells from the breast by the processes known as core biopsy or fine needle aspiration. A definitive diagnosis should be achieved in the minimum number of assessment visits wherever possible and women should not have to make more than two visits for interventional procedures. The Northern Ireland Breast Screening Programme currently detects 3 Analysis of Statistical and QA information reports (2000-2005) 4 DHSSPS (2003) Priorities for Action 2003-2004 6

approximately 5.6 invasive breast cancers and around 1.7 non-invasive cancers per 1000 screens in Northern Ireland. It is now widely accepted that the multi-disciplinary team forms the basis for best practice in the management of breast disease 5. These constituent members of the breast team are generally divided into two separate but interdependent groups: The Diagnostic Team (Breast Assessment) The Cancer Treatment team The role of the breast clinic is both to diagnose and treat breast cancer and to treat and reassure patients with benign breast disorders. The key component members of the breast assessment multi-disciplinary team are: Breast Specialist Clinician (normally a consultant surgeon with an interest in breast disease) Associate specialists, breast clinicians, staff grade surgeons and specialist registrar trainees Specialist radiologist Specialist radiographer Pathologist (and laboratory support staff) Breast care nurse Clinic staff Administrative staff The cancer treatment team may include members of the diagnostic team as well as a number of other clinicians specifically involved in the treatment of cancer. These structures not only bring a range of specialist knowledge and skills together in determining the diagnosis and management of breast disease but also put in place a system of governance by ensuring checks and balances through an ability of the team to debate and challenge aspects of patient management. 4.3 Accountability structures The Northern Ireland Breast Screening Programme is commissioned by the four HPSS Boards. Screening services are provided and managed by the HPSS. Screening unit staff are accountable through the Area Clinical Director- Breast Screening Unit to the HPSS Trust management which in turn is directly accountable to DHSSPS. 5 Journal of cancer Surgery (2005) Guidelines for the management of symptomatic breast disease. The Association of Breast Surgery at BASO Royal College of surgeons of England 7

4.4 The Regional Advisory Group The NHS Breast Screening Programme guidelines place a requirement to have a regional Advisory Group for breast screening in Northern Ireland. The main remit of the group is: To advise the DHSSPS on the development and delivery of the Breast Screening Programme in Northern Ireland. To monitor performance against national quality standards. To advise on both the quality assurance programme and quality issues. To co-ordinate regional activities within the Breast Screening Programme. 4.5 Key roles identified within the structures are as follows: Director of Quality Assurance for Breast Screening: The post-holder is a consultant radiologist. The role of this post is to take the lead in the development of the Regional Quality Assurance Programme for Northern Ireland and give advice to all relevant agencies Boards, Trusts and DHSSPS concerning the provision of a high quality and effective screening programme. This post is based at the Quality Assurance Reference Centre 6. Regional Quality Assurance Coordinator: The post-holder is a consultant in public heath medicine. In conjunction with QA Directors (mammography and cervical screening) has responsibility for ensuring the provision of a high quality and effective screening programme throughout Northern Ireland. This post is based at the Quality Assurance Reference Centre. The advisory structure for breast screening programmes as shown at Appendix 5 outlines the lines of responsibility for the commissioning, delivery of the breast screening programme. The employer accountability structure is shown in Appendix 6. 4.6 Clinical and QA Guidelines The Northern Ireland Breast Screening Programme takes its clinical standards and QA guidance from the NHS Breast Screening Programme publishes a range of guidelines for specific professions working within the service as well as guidelines for issues such as QA visits, breast cancer screening assessment and the management of incidents in the NHS Breast Screening Programme. The symptomatic service is also expected to adhere to the British Association of Surgical Oncologists standards for the management of symptomatic breast disease. It is 6 NIBSP (2001) NIBSP Advisory and Organisational Structures 8

recommended that screening, assessment and symptomatic services are provided if possible in one location. 9

5 Key Findings This section of the report examines the circumstances and key events that led to the recall of 44 women at Antrim Area Hospital, (following referral from the Breast Screening Programme), over the period January 2004 to October 2005. This section will also consider the use of Clinical and Quality Assurance guidelines within the Northern Ireland Breast Screening Programme as set out within the DHSSPS terms of reference. The findings are based on the written and verbal submissions from organisations and key personnel involved in the incident and its management. These circumstances are discussed within four key parameters: 1. How workforce issues impacted on the service. 2. How the identified consultant radiologist s competency and clinical performance was managed in the Trusts in which he worked. 3. How the selection and recruitment process for medical consultants impacted on the circumstances leading to this incident. 4. How the use of clinical and QA guidelines influenced the quality and provision of breast screening services. 10

5.1 Workforce issues and their impact on the service 5.1.1 The review panel noted that from September 2000, The Northern Ireland Regional Advisory Group, the Northern Health and Social Services Board and Antrim Area Hospital identified difficulties in maintaining the breast screening, assessment and symptomatic breast services because of workforce shortages in radiology and radiography which had an adverse effect on radiological services in general. These concerns were particularly acute in the Northern Board s Breast Screening Programme where a single handed, senior breast radiologist had worked in the breast screening unit in Antrim Area Hospital for long periods between 2000 and 2003. As a result of these workforce concerns, the Northern Health and Social Services Board submitted frequent and ongoing communication with the DHSSPS through a number of routes, including the Chief Medical Officer s office, the Workforce Development Unit and the Permanent Secretary s office. 5.1.2 Examination of the Analysis of Statistical and QA information 7 for this period shows that the Breast Screening Programme in the Northern Health and Social Services Board was performing well and no concerns had been raised about the outcomes for women in the breast screening programme. It is noted that although the term single handed radiologist is used in describing the way in which the Northern Board s breast screening programme operated at this time, radiology work within the programme was complemented by the skills of a full multidisciplinary clinical team. It was the collective effort of this team that maintained the quality and performance of the breast screening service. 5.1.3 Prior to 2003 the identified consultant radiologist was working in the Altnagelvin Hospitals Trust in 2000/2003 as part of a larger radiology team undertaking intermittent sessions in breast screening and assessment. The identified consultant stated that at this time he carried out breast radiology sessions approximately once every five weeks. There were no concerns expressed about his work during that time in the Altnagelvin Hospitals Trust. The Wilson Report indicates that there were no cases in which the identified consultant radiologist was involved in the Altnagelvin Hospitals Trust that raised concern. During this time in acknowledgement of the workforce shortages in Antrim Area Hospital, the identified consultant radiologist was released from Altnagelvin Hospitals Trust to provide support in the Antrim Area Hospital breast unit. During this period he worked in partnership with the senior breast radiologist and the multi-disciplinary breast team. No identifiable concerns had been raised at that time about the identified consultant s clinical work. 7 NIBSP Statistical Profile (2003 2004) 11

5.1.4 In July 2003 the identified consultant was recruited to Antrim Area Hospital to a permanent post of consultant in general radiology with a special interest in breast imaging, to work within a team of 2 consultant radiologists undertaking breast work, one of whom was the Clinical Director of Radiology. When the Clinical Director left the post in Antrim Area Hospital, another consultant who has been undertaking a small number of breast screening sessions took over the post of Clinical Director (January 2004) and dropped his breast radiology sessions by agreement of the Trust. The identified consultant was then required to work as the sole breast radiologist in the Breast Screening Programme and symptomatic service in Antrim Area Hospital. 5.1.5 To offset the continuing shortfall in the breast screening and assessment workforce it is commendable that Antrim Area Hospital developed the roles of two radiographers as film readers in 2003. Film reading radiographers help in the task of reading mammograms when the films are also read by a consultant radiologist. This double reading is considered best practice and is undertaken by the majority of units in the UK. However, the task of directing and interpreting additional mammograms taken during the assessment process is usually the responsibility of a consultant radiologist. 5.1.6 Senior staff in Northern Health and Social Services Board and Antrim Area Hospital continued to focus predominantly on the issue of radiologists as a workforce problem and, as a result the service was continuously described as being under threat. Actions taken by the Trust in relation to the recruitment of radiologists are commended even though unsuccessful in filling the vacant post. Antrim Area Hospital undertook an overseas recruitment effort to recruit a radiologist in to the vacant breast radiology post with no success. The radiologist workforce issue was also emphasised in the annual reports compiled by the QA Director for Breast screening on behalf of the Regional Advisory Group. 5.1.7 Information provided by DHSSPS to the review panel shows that significant focus was placed on workforce issues for radiological services, with increases in investment in the numbers of radiology specialist registrars, consultant radiologists and radiography staff. These increases are outlined in Tables 2 and 3: 12