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Radiology report falls short

Old boys club culture not acceptable when lives are at stake
Kyle Wells

 UPDATED:  Families and politicians have expressed disappointment following a report released by the ministry of health on Tuesday, September 27 on unqualified radiologists working in BC.

The report, written by BC Patient Safety and Quality Control chair Dr. Doug Cochrane, looked into the events and circumstances that led to four radiologists performing readings on CT scans despite being unqualified to do so. In Powell River, Dr. Mansukhlal Mavji (Charlie) Parmar read CT scans between April and October 2010, despite a voluntary restriction. As a result of misreadings, nine people in Powell River had their health care “compromised,” according to the report.

Joan Graham, daughter of John Moser who died from cancer in January and had a misread scan from August 2010, thinks the report falls short of fixing the problem that she believes possibly led to her father’s death. She also believes the recommendations will not fix the lack of accountability or oversight that she thinks is at fault.

“They’ve put a little lipstick on it and a little mascara and they are bringing it out again for everyone to look at and it looks prettier,” said Graham, “but it’s just basically the same old, same old.”

An independent agency, separate from health authorities and BC Patient Safety and Quality Council, which is run by health system stakeholders, needs to be established to oversee health care in the province, she said. She envisions it as a body that anyone with concerns, whether it be patients, family or medical staff, can go to without fear of repercussion and know they will be heard free of any internal politics.

“There’s an old boys’ club that’s been around for many years and anyone who works with any type of teamwork, we all know that we kind of get each other’s backs,” said Graham. “This time people actually died as a result of it.”

Dr. Richard Lupton, senior medical director for coastal community of care, a region of Vancouver Coastal Health, said a culture of not speaking out may have contributed to the incident and is something that needs to be addressed in the health care system.

“Physicians are a very cohesive group and they do tend to look after each other,” said Lupton. “I don’t want it to be reported as being the conspiracy of silence, because that’s certainly not true. But on the other hand, medical staff and particularly smaller medical staffs are a very cohesive, collegial bunch and it puts them in a very difficult situation.”

Lupton said the recommendations made by the report will help provide objective measurement of a physician’s abilities. By having the health authority take on more of the responsibility of assessing a physician’s abilities, more opportunity will be provided for staff to voice concerns.

“I think that there will be [created] a situation whereby all physicians will be assessed on an equal basis and it will be objective and not subject to local pressures,” said Lupton.

Powell River-Sunshine Coast MLA Nicholas Simons is attempting to organize a meeting between families affected by this situation and health minister Michael de Jong. He has spoken to a few of the families and said that in general they are frustrated over the report and do not feel the recommendations will restore their trust in the system.

“It’s disappointing all round,” said Simons. “I think there are a number of questions that the minister still needs to answer.”

Lupton said the search is underway for a new medical director at Powell River General Hospital (PRGH) and that Dr. Pawel Makarewicz, who is resigning from the position, is involved in the process of finding a replacement. The new medical director will most likely be recruited from within the hospital.

There have also been a number of applicants for the position of radiologist at PRGH, following the resignation of Parmar. In the meantime, CT scans are being sent to the Lower Mainland for analysis.


Province releases review of unqualified radiologists

Second phase of report reveals systemic problems that led to misreadings

Phase two of BC Patient Safety and Quality Council chair Dr. Doug Cochrane’s review of four unqualified radiologists in BC, including one in Powell River, has been released and reveals the missteps that led nine patients to have their “care compromised” at Powell River General Hospital (PRGH).

The Phase 2 report can be viewed here.

The review outlines in detail the events that led to the issues in all four situations and outlines 35 recommendations for action at all levels of the health care system. Cochrane and minister of health Michael de Jong discussed the report at a press conference on Tuesday, September 27.

Dr. Patrick O’Connor, Vancouver Coastal Health (VCH) vice-president of medicine, quality and safety, spoke with the Peak about the report and the specifics of the situation with PRGH and Dr. Mansukhlal Mavji (Charlie) Parmar, who between April and October 2010 performed CT scan readings despite a voluntary restriction on his licence.

Cochrane’s report states a total of 891 scans of 774 patients were performed and nine patients were “deemed to have had their care compromised because of the error in scan interpretation.”

O’Connor confirmed that of those nine, three patients failed to have the spread of cancer detected on their CT scan reading and were not offered the corresponding therapy. O’Connor said one of those patients has since died and the other two remain in care.

“I cannot say with certainty that we would have affected a cure,” said O’Connor. “I can also not say with certainty that we would not have prolonged some lives and improved their care. You would like to think that if we’d made the correct diagnosis and appropriate therapy was applied that we would have cured those diseases. It is not certain by any stretch.”

Due to “the limitations in the reporting and in the recording of image date” Cochrane was unable to conclude in the report whether any misreading of obstetrical ultrasounds had led to compromised care.

Cochrane’s report speaks of staff being aware of problems with Parmar “from the time the scanner was commissioned.” O’Connor said he believes this went back further and physicians and technical staff used an informal system of rereads and second opinions in an effort to make up for the shortcomings of Parmar’s abilities. The report reveals that while concerns were raised with the site coordinator for diagnostic imaging, no action was taken. The issue only became known to VCH once a group of physicians came forward with concerns in October 2010.

“People knew for a long time that some of the reports were not complete and they were working around that in the community,” said O’Connor. “In our report we actually detail that the physicians expressed both relief and grief that they knew this had been going on and hadn’t brought it forward.”

O’Connor said that three levels of error led to the situation at the Powell River hospital.

First, Parmar breached his own voluntary undertaking with the College of Physicians and Surgeons of British Columbia restricting him from performing the readings, nor did he inform the College when he took additional training to have them approve the training.

Secondly, O’Connor described a “system failure” that limited communication between the college and VCH over the restrictions. PRGH received one letter from the college in 2001 advising administrators of the restrictions. This letter sat in a file and was not required to be consulted during yearly relicensing for Parmar. The failure here, said O’Connor, is not having the connection between having a licence and having a restriction and not having that information centralized and readily available.

“Should Vancouver Coastal Health been aware of that? Yes,” said O’Connor. “It really depended on someone going back to the file. That is a failure. It’s a failure of our system and it’s a failure locally because it was in the file there.”

Third, O’Connor said that the College made a mistake in not noticing the restrictions during the accreditation of the new diagnostic facility in Powell River when the CT scanner was installed.

O’Connor said that while VCH has no plans to take action against any individual administrators, PRGH medical director and chief of surgery Dr. Pawel Makarewicz resigned from his position on Monday, September 26. After 10 years in the position Makarewicz has his own reasons for resigning, said O’Connor, and will be continuing his own local practice. Makarewicz could not be reached for comment.

“From our perspective he’s done a very good job in 10 years there,” said O’Connor. “This is a system error on VCH’s side and I can personally say I hoped I would have looked in that file, but I can’t guarantee you I would have. Our systems were just not good enough to ensure that was going to happen and that’s what we’re changing.”

Parmar resigned his BC practice privileges in February when the minister made the issue public and is now the subject of a professional breach hearing by the College. Parmar will not be able to reapply for privileges until the review is complete, should the outcome allow this. While Parmar took part in VCH’s own internal review of the situation, he “declined the opportunity” to take part in Cochrane’s review.

Now that the problems have been clearly identified, O’Connor said VCH is committed to fixing the systemic problems. A team-building process has already finished its first phase at PRGH and improvements to the culture there will continue. Recommendations for clinical audits suggested in stage one of Cochrane’s report are also ongoing. VCH’s goal is to standardize review processes throughout the authority, with all rural and urban health care services.

O’Connor also explained their job now is to regain the public’s trust in the health care system. He believes putting a centralized audit process in place is a first step toward that end.

“We were all shocked about this,” said O’Connor. “This should not have happened. This should not have happened to patients or the community of Powell River.”