Documents reveal pressure over Central Health radiology errors

Officials with a central Newfoundland health authority knew about problems with the work of two visiting doctors months before the public was informed, and were also put under enormous pressure by the provincial government to go public before they knew the extent of a health scare, documents show.

Central Health disclosed last November that it was reviewing the work of two radiologists who had worked at James Paton Memorial Hospital in Gander, and noted that a patient's recent complaint had triggered the action.

But emails, notes and other records obtained by CBC News through provincial access to information legislation show that Central Health had not only been aware of the issue for six months earlier than it had disclosed, but that officials were led to believe a patient was suing.

Moreover, the records show that Central Health had become embroiled in a high-pressure tangle with the Newfoundland and Labrador government over the issue, including what information should be released, and how quickly.

Together, they raise questions about whether Central Health was effectively pushed into telling the public about the radiology mistakes before medical professionals felt they had done their homework in assessing what was actually happening.

The radiologists' mistakes were first disclosed in a Nov. 3 news release, which yielded heavy media coverage of what was thought to be a significant health scare. 

Although thousands of X-rays, CT scans and MRI scans had to be reviewed, the subsequent investigation showed that only 15 people had been given wrong information, and that two patients were actually harmed by the errors. One of them, the review found, had suffered unnecessary and prolonged pain.

How the mistakes happened

Documents show that Central Health learned that the two visiting radiologists had used two computer monitors to review patients' scans. The left screen presented past results, with the right screen showing the latest scan, allowing the specialist to make comparisons.

But in these cases, somehow, the presentations were reversed, with the older results appearing to be the most recent.

Neither of the physicians noticed, and the backup systems did not alert them to the mix-up.

By early October 2011, supervisors at Central Health were documenting problems with the radiologists' work, and the more they looked, the more problems they found.

One radiologist, for instance, found that one of the visiting specialists had noted that a patient had two kidneys, even though the image only showed one. Another time, a case of pneumonia was missed, while in a separate patient the size of a kidney stone was significantly larger than the radiologist reported.

Health department brought into loop

By Oct. 27, the Department of Health and Community Services was brought into the loop, a day ahead of a cabinet shuffle that would bring a new player into the health portfolio.

Susan Sullivan, who took over the health department from Jerome Kennedy, was briefed Nov. 3 — but by then relations had already become much more excited between the government and Central Health, which, like other regional health authorities, is legislated to operate at arm's length from the province.

Last November, Sullivan's office told CBC News that while the minister — who represents a central Newfoundland district — was being kept abreast of the issue, Central Health was handling the newly disclosed radiology problem.

But the emails show that Sullivan's office was indeed in control of the matter, particularly on the matter of public notification.

Indeed, the department had already primed Central Health to be ready for an expedited release. On Nov. 2, the day before Sullivan was briefed, Central Health cautioned the department that "we are still in the process of confirming (investigating) all of these cases)," and that it needed several more days to get its facts straight.

Nonetheless, early on the afternoon of Nov. 3, Central Health's communications director sent an urgent email to senior managers.

"We were just advised to go public ASAP — expectation is this afternoon," Stephanie Power wrote.

The records show that the firm direction from the government that day triggered a pressure cooker inside Central Health, as officials wrestled over the wording of a statement that the authority was being told to release.

Patients, MDs had not yet been warned

Central Health’s concerns, apart from an incomplete investigation, included the fact that patients had not yet been notified, nor had regional administrators and physicians.

The health department did not budge from its position, however. Central Health was told "this is going before Social Policy Committee (of Cabinet) this morning and that it is anticipated that the direction will come to us following that meeting," Power informed senior managers on the morning of Nov. 3.

After a feverish exchange of information, in which government officials also gave approval to the wording of patient letters, a news release went out that afternoon.

Amid all of the activity, government officials appeared concerned about how the news would be received. In one case, Central Health was told the department preferred the word "review" to "investigation."

Central Health's lawyers were also alerted, although it is not known what legal advice the authority received. About a dozen pages of those records were held back, with Central Health citing lawyer-client privilege.