The critical untrasound incidents in Drogheda and Galway Hospitals

Woman goes to Drogheda Hospital on July 22, 2009 and has a pelvic ultrasound scan transvaginally on an 8 week pregnancy. Mother was told that there is no heartbeat and given options by staff doctor. The woman had four previous miscarriages. She decided on a D&C and was given abortifacient medication (? Methotrexate) and a following day admission was arranged for a D&C to evacuate the uterus. Later that day, she had a transabdominal ultrasound done at a GPs surgery where the foetal heartbeat was loud and clear. The baby Michael was born on the 6th March 2010 and is very well.

An internal Drogheda Hospital report has already been done and the findings were

• The diagnosis was based on the opinion of one doctor. Best practice suggests that another scanner, preferably an experienced sonographer — an ultrasonic image specialist — confirms the diagnosis before it is made.

• The scanning machine in the EPU was six years old, “was subjected to a heavy workload” seven days a week and displayed “evidence of fatigue”. It was not adequate to “accurately assess early pregnancies and their complications”.

• The examination couch was not suitable. It did not split fully, which did not allow for optimal scan views.

• There were no guidelines in place regarding scanning techniques and viewing scans.

• There were no permanent, trained scan staff attached to the EPU, meaning the experience of staff varied every six months, with some getting “on-the-job training”.

• There were no written guidelines for the investigation and management of early pregnancy problems.

In the report, the hospital made eight recommendations to improve its facilities, key elements of which have not yet been acted on. Other recommendations were only acted upon months after the misdiagnosis.

For example, the old scanner in the unit was only replaced last January — and was still being used on pregnant women for six months after the incident.

A sonographer will only be put in place next month, a full year after the incident. The sonographer will then only be available for four hours in the morning.

This matter should again be brought to HIQA. and proper accreditation standards should be insisted upon right across the entire maternity section.

The Galway case merely underlines the case for national quality guidelines in this area.