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• April 2010 - Report on a complaint made by Mr Brown, Co Mayo against the Health Service Executive

April 2010 - Report on a complaint made by Mr Brown, Co Mayo against the Health Service Executive

  Investigation Report on a complaint made by Mr Brown, County Mayo against the Health Service Executive (pdf, 235 kb)

Summary of Investigation Report

Mr Brown & the HSE - Summary (Text Version)

  Summary of an Investigation Report on a complaint made by Mr Brown, County Mayo against the Health Service Executive (pdf, 26 kb)

Text Version of Report

Contents

Part 1. Introduction

 

1.1 Background

1.2 Complaint received

1.3 Further HSE Correspondence with Mrs Brown (RIP)

1.4 Hospital response

Part 2. Preliminary Examination

2.1 Hand-written note on Test Result

Part 3. Investigation

 

3. Investigation - Introduction

3.1 Investigation - Response from the Health Service Executive

On 22 August 2006 the HSE responded to the Statement of Complaint in the following terms:-

3.1.1 Investigation - Handling of Diagnostic Reports

3.1.2 Investigation - Action Taken to Improve Procedures

3.1.3 Investigation - Follow up System for Diagnostic Results

3.1.4 Investigation - Notification of Hospital Appointments to Deceased Persons

3.1.5 Investigation - Renewal of Medical Card

3.2 Investigation - Interviews

3.2 Investigation - Interviews - Introduction

3.2.1 Investigations - Interviews - Mr Brown, Complainant

3.2.2 Investigation - Interviews - Dr Greene, Consultant in Respiratory Medicine, Merlin Park Hospital, Galway

3.2.3 Investigation - Interviews - Dr Murphy, former Research Registrar, Merlin Park Hospital, Galway (2003to 2005)

3.2.4 Investigation - Interviews - Mrs Kelly, Senior Technician, Lung Function Test Unit, Merlin Park Hospital, Galway

3.2.5 Investigation - Interviews - Ms Byrne, Clerical Officer, Secretary to Dr Smith, Consultant Physician and Gastroenterologist, Mayo General Hospital, Castlebar

3.2.6 Investigation - Interviews - Ms Butler, Clerical Officer, Secretary to Dr Mallen, Consultant, Mayo General Hospital

3.2.7 Investigation - Interviews - Dr Smith, Consultant Physician and Gastroenterologist, Mayo General Hospital, Castlebar

3.2.8 Investigation - Interviews - Dr Charles, Locum Consultant, Mayo General Hospital

3.2.9 Investigation - Interviews - Dr Doyle, Mrs Brown's General Practitioner

3.2.10 Investigation - Interviews - Mrs Moore, Personal Secretary to Dr Smith, Consultant Physician and Gastroenterologist, Mayo General Hospital, Castlebar

3.2.11 Investigation - Interviews - Mr Martin, Postman, Mayo General Hospital, Castlebar

Part 4. Analysis

4.0 Analysis - General

4.1 Analysis - Clinical Judgement and the clinical consequences of maladministration

4.2 Analysis - Communication of Test Results

4.3 Analysis - Receipt of Test Results in Mayo General Hospital

4.4 Analysis - The Missing Manuscript note on the Lung Function Test report

4.5 Analysis - Appointment letter for Endoscopy Unit

4.6 Analysis - Reminder Notification for Medical Card

Part 5. Findings

5.1 - 5.5 Findings - The Lung Function Test

5.6 Findings - Missing Manuscript Note

5.7 Findings - Implications for Health and Welfare of Patients

5.8 Findings - Hospital Information System

5.9 Findings - Examination of the Brown family's complaint

Part 6. Recommendations

 

Recommendations

Appendix 1

Appendix 1 - Lung Function Test