Published: 18/04/2002, Volume II2, No. 5801 Page 6 7
The Commission for Health Improvement has called for future Department of Health guidance on investigations and inquiries to specify that external inquiry reports 'should be available in the public domain'.
CHI's suggestion comes in the wake of its investigation into errors at the West of London breast screening service, which left some women waiting almost two years for a cancer diagnosis.
CHI says its work was hampered by lack of access to a confidential report on the imaging directorate which was undertaken for the DoH, and to which the DoH refused access on the grounds of confidentiality.
Referring to the DoH report, the investigation says that although CHI had no remit 'to re-investigate matters which have been the subject of previous inquiries', the 'history of inquiries into practices within the imaging directorate is relevant because [the West of London breast screening service] is based within the imaging directorate'.
In its report, CHI criticises 'unacceptable and avoidable' failures in the screening service, but the investigation does not identify any individuals at fault.
The service is part of Hammersmith Hospitals trust's imaging directorate, which was the subject of a number of internal and external investigations over allegations that patient safety had been compromised and staff victimised for raising concerns. The screening service was suspended between June and December last year because of its failure to stick to national protocols.
The CHI investigation, requested by the trust, followed the discovery of a recall error in a patient's file which led to an external audit of the files of all women who had attended the service since 1993.
A total of 174,000 screening results were reviewed and it was found that 123 women had not been recalled for immediate further assessment. As a result, 11 women had their diagnosis of breast cancer delayed and one woman, whose diagnosis was delayed 15 months, subsequently died of breast cancer.
John Cooper, chief executive when the problems occurred, took early retirement last October. Last summer, he told HSJ: 'Ultimately, I am responsible for the service.'
Medical director Professor Rory Shaw, who was appointed chair of the National Patient Safety Agency last summer, told HSJ at the time of his appointment that his experiences of the problems would help in his new post.
However, though the report says 'senior trust management failed to detect and act on the ineffective line management and accountability arrangements' and that there was 'no effective leadership in the breast screening unit and a lack of clear management of the unit by the trust', no individual managers are named.
CHI chief executive Dr Peter Homa said: 'Our findings are that this was a systems failure. There was no effective leadership in the breast screening unit in the host trust.We found there was a shortage of staff and some poor working relationships.
'There is no single individual responsible for this failure. In essence, this was a systems failure.'
Trust chief executive Derek Smith told HSJ he hoped the report would draw a line under the problems of the screening service and the imaging department, and that it was right that individuals were not named.
He said all the managers involved were 'competent people' and there had been 'a corporate failure as well as a screening failure'.
He said management accountability had now been improved, and added: 'I have no doubt thatI am accountable for the service and I have a management structure accountable to me for that.'
In terms of the resumed service, he said: 'We are just about back to full speed now. The big issue for us is to deal with the backlog. That is something where we are going to undertake Saturday working. We ought, as long as everything goes well, to catch up by July 2003.'