HOW MANY MORE WERE MISLED OVER BABY SCANS? Shock Report Says Poor Training Led to Wrong Diagnosis of Miscarriages; A People Problem.Not the Machines

Daily Mail (London), April 19, 2011 | Go to article overview

HOW MANY MORE WERE MISLED OVER BABY SCANS? Shock Report Says Poor Training Led to Wrong Diagnosis of Miscarriages; A People Problem.Not the Machines


Byline: Petrina Vousden Health Editor

TWENTY-FOUR women were wrongly told they had miscarried because of poor medical training at 16 hospitals throughout the country, a damning report has found.

And while it has been confirmed that 22 of the women went on to give birth to healthy babies, experts admitted that no one will know how many of the 70,000 miscarriages that are estimated to have occurred in the timeframe involved were misdiagnosed.

The legacy of doubt for thousands of Irish mothers was last night made worse by the fact that the 16 hospitals implicated in the scandal are not named, while one support group went so far as to claim that the 24 cases identified were 'just the tip of the iceberg'.

Some of the conclusions are, however, clear and unambiguous. The failure was down to people not machines, rather than had been first indicated. Inadequate staff training and over-reliance on ultrasound led to the alarming errors.

Astonishingly, six babies survived even though their mothers underwent procedures to remove the contents of their wombs. However, two of the babies - whose heartbeats were only discovered after the procedure - later died.

The pregnancy specialist who led the investigation, Professor William Ledger, admitted it would never be known if the babies died as a direct result of the procedure.

Last night the HSE and the Institute of Obstetrics and Gynaecology issued apologies to the families affected.

While an old scanning machine at Our Lady of Lourdes Hospital in Drogheda was blamed for some of the miscarriage misdiagnoses which prompted the inquiry, the problems at most hospitals were down to poor training at all levels of medical expertise.

Melissa Redmond, from Donabate in north Co. Dublin, was wrongly told she had miscarried in July 2009. She was given a drug to induce labour and scheduled to have a D&C - Dilation and Curretage - procedure.

But her instinct told her she was still pregnant. She went to a local family doctor for a second scan which detected a heartbeat. Her son, Michael, celebrated his first birthday last month.

The 56-page review published yesterday reported 18 miscarriage misdiagnosis cases between 2005 and 2010. The remaining six cases in the review date back as far as 1987.

Professor Ledger said that the majority of ultrasound machines were properly maintained and less than five years old at the time of misdiagnosis.

And Obstetrics and Gynaecology Professor Michael Turner said: 'I think the emphasis needs to be on improving the quality of patient care and improving the quality of staff training. This is about people, it's not about machines.'

Professor Ledger said the misdiagnoses occurred at the very early stages of pregnancy when ultrasound can fail to detect a foetus or heartbeat.

'The hazards of the use of ultrasound to diagnose a miscarriage in very early pregnancy have been repeatedly highlighted since the introduction of this technique in the 1970s and there have been recent reports of misdiagnosis of miscarriage from the United Kingdom and Australia,' he said.

The report recommends that any patient who requests a second ultrasound should be provided with this service.

It also said patients should be allowed to delay a medical or surgical procedure in order to allow 'time to pass' before a second diagnosis with ultrasound.

Ultrasound and its usage is studied as part of the curricula for examination for doctors.

But in future there will be mandatory training in ultrasound with competence assessment.

Consultants and registrars accounted for almost 80 per cent of the professionals who made the primary diagnosis of miscarriage of suspected miscarriage.

Fourteen of the initial ultrasound scans were carried out at seven weeks' gestation or less. In 15 of the cases reviewed, the second ultrasound did not show any change in the diagnosis. …

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