'Sorry must be followed by reform', says family of man who died due to medical misadventure
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HSE chief clinical officer Dr Colm Henry will lead any reforms needed following a coroner’s recommendations after the death of a lung cancer patient, the HSE confirmed.
The family of Shane Banks, 43, made a moving plea for reform to be “monitored, open and transparent” after the coroner’s finding of medical misadventure.
Mr Banks died in Galway University Hospital (GUH) following two operations for lung cancer within weeks of each other during June 2019.
His wife, Ciara Banks, and mother of their three young children, said the family still has many questions about their loss.
“We heard the word ‘sorry’ mentioned a lot during the course of the inquest. As a family, we, of course, note the apologies and they are welcomed,” she said.
“An apology though is only meaningful if it’s backed up by clear specific actions that are monitored and open and transparent. “
Ms Banks said the evidence raises “bigger questions about management within the Irish healthcare system”.
The “serious issues” revealed could happen in any hospital, she said.
She spoke of how much Shane loved his family, his friends, surfing, the family farm, and working at Sligo IT.
“It is too late for Shane and our children,” she said. “Shane will and has not been here for key moments in their lives from first day at school, first communion to going to football matches or teaching them to swim and surf. But we can try to ensure it doesn’t happen to any other family.”
Among the three recommendations made by coroner Dr Ciaran McLoughlin, were that the HSE, doctors’ training colleges, and the Irish Medical Council collaborate on a national mentorship programme.
The inquest heard the cardiothoracic surgeon, Professor Mark DaCosta, was under supervision for his cardiac practice and advised to only carry out “straightforward” procedures.
Similar supervision was not over his thoracic (lung) operations. A consultant at GUH, Dr Kevin Clarkson, told the inquest: “I think in retrospect we fouled up and badly, despite input from some of the most senior figures in these islands.”
The inquest also heard Mr Bank’s surgery was re-scheduled due to pressures caused by overcrowding.
“The office of the HSE’s chief clinical officer will lead on our consideration of the coroner's recommendations, in consultation with stakeholders,” a HSE spokeswoman said this week.
She said clinical audits and “a range of activities and supports” are already in place.
The Royal College of Surgeons Ireland said mentorships start within a hospital, and they can “explore alternative options” when a situation is escalated to them.
“It is important that departments and teams are large enough to provide overlapping expertise to mitigate the risks of surgeons practising in isolation,” a spokeswoman said.
The inquest heard the cardiothoracic department at GUH ran for nine years with just two consultants and that a locum was not hired if one consultant was on leave or ill.