Blunder affects hundreds of patients of St Vincent’s Hospital Sydney
More than 500 patients undergoing cancer mutation testing have been affected by a blunder that’s led to at least one ‘adverse clinical health outcome’.
More than 500 patients who have undergone genetic testing to determine if they carry mutations that could put them at a higher risk of developing cancer are at the centre of a blunder at St Vincent’s Hospital Sydney.
There has been an adverse clinical health outcome for one patient as a result of the blunder and The Australian understands about 20 others had experienced what’s considered serious clinical errors, such as being provided with the wrong test result.
Errors were detected with hundreds of other patient files too, but for less serious incidents, such as misspelled names or they were not provided with appropriate after-care.
The incident is understood to have happened within the hospital’s Cancer Genetics Service and has affected some patients who were seen by former senior physician Allan Spigelman between April 2022 and June 2023.
The Australian has seen a document, signed by the hospital’s chief executive Anna McFadgen, which states the hospital has conducted a review known as a “clinical lookback” which it says was prompted after the discovery of irregularities in the medical records of three patients.
It is understood a group of about 500 affected patients was contacted in recent weeks.
One patient, who spoke with The Australian on the condition of anonymity, said they were distressed by the incident but were clueless about what prompted the review or the extent to which patients were affected.
“The tone and lack of sufficient information in the letter sent to me felt disrespectful and caused me significant distress,” the patient said. “I’ve lost trust in St Vincent’s.”
In a statement, the hospital said it had been aware of irregularities since September 2023, had been urgently investigating, and updated the most significantly affected patients as soon as those irregularities were discovered. It also alerted senior health officials within weeks.
“In September 2023, St Vincent’s became aware of some irregularities in the medical records of three patients in its cancer genetics service relating to a clinician, who largely saw patients from his private office or rooms via telephone during the Covid pandemic,” a hospital statement says. “There has been an adverse clinical health outcome for a single patient following the provision of incorrect advice by the clinician. The patient has been informed of the review. The process of confirming what took place and providing all necessary support for this patient is ongoing.
“For around 1100 patients in the review, no errors or irregularities were detected in their records. In approximately 520 records, we discovered matters such as poor clinical documentation, incomplete correspondence, and a lack of genetic counselling.
“And in approximately 20 records, we discovered errors that carried potential risk – even if, ultimately, there had been no harm to these patients.
“St Vincent’s first reported this matter to NSW Health in October 2023 – shortly after becoming aware of the irregularities – and has provided regular updates on developments to NSW Health since then.”
In 2016, St Vincent’s Hospital was embroiled in a chemotherapy dosing scandal when more than 100 patients in NSW were given doses lower than what was recommended. The incident and the handling of it were criticised in a select committee review released in 2017.
The investigation found that while the hospital was aware of the underdosing in June 2015, it was not made public until February 2016, and patients and their families were not alerted quickly enough.
Given that prior investigation, The Australian asked the hospital why clinical oversight had not been in place to prevent such an incident from occurring.
“Prior to December 2019, the clinician provided cancer genetics services supported by genetics counsellors,” a hospital spokesman said.
“With the outbreak of Covid in January 2020, he adapted his service model over time, slowly reducing the genetics counsellor’s role. By the 15 months covered by our lookback review, he was operating as a ‘solo practitioner’, largely seeing patients privately in his office or rooms and often by telephone.
“Following the clinician’s departure from the hospital in mid-2023, St Vincent’s has now returned the service to a model which emphasises the important role other clinicians play in delivering the service, including the role of genetics counsellors.
“We have also begun a partnership with the cancer genetics service at Prince of Wales Hospital and are benefiting from its extensive experience in this clinical area.”
In response to this latest incident, the hospital says the clinician has not worked at the hospital since mid-2023 and has been referred to the Australian Health Practitioner Regulation Agency by St Vincent’s Hospital Sydney.
St Vincent’s Cancer Genetics Service provides genetic counselling, advice, and testing to eligible patients and their families and is reported to care for more than 2,000 families across the state.
The Australian has approached Professor Spigelman for comment.
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