A Dutch hospital failed to tell Irishwoman Adrienne Cullen it had discovered what went wrong with her treatment before her death, it has emerged.
UMC Utrecht hospital also failed to tell Ms Cullen's widower Peter Cluskey about the missed opportunity to identify what led to her cervical cancer until he found out about it himself.
Ms Cullen died a year ago, on New Year’s Eve 2018, as a result of medical negligence.
Last May, the hospital published a review showing there had been two opportunities to save Ms Cullen’s life by diagnosing what was then early-stage cancer.
It had already been known that in 2011, the results of a tissue sample were lost before they reached her doctor. But the report revealed a second missed opportunity to identify her cancer early, when a pathologist and a pathology technician misread a tissue sample that was later judged to be cancerous by 11 other pathologists.
While the hospital review listed as one source an expert report from the Dutch pathology association dated November 28th, 2018, it was only when Mr Cluskey was contacted privately by a member of staff several months later that he learned the significance of this footnote.
The doctor told him this date – over a month before Ms Cullen’s death – was when the pathology results were sent to the hospital, showing the substantive cause of the failure to diagnose her cancer.
Mr Cluskey said hospital executives had discussed the contents of their review with him on May 6th, several days before it was published, but made no mention of the date of delivery of the pathology findings.
“UMC Utrecht believed I would never find out that it let Adrienne go to her death without telling her,” said Mr Cluskey. “They had one particularly appropriate opportunity to tell me, on May 6th, and said nothing.”
Mr Cluskey said he raised the issue with the hospital at meetings in September and October and established that senior executives had been told of the pathology results, but the hospital has yet to say whether its chief executive was aware.
“Were it not for one of their own doctors who regarded their behaviour as shabby and inhuman, I would never have found out.
“Only when I confronted them with the information I already had did they confirm, and even then did so reluctantly and with no detail of who knew what and when.”
Dilemma
A hospital spokeswoman told The Irish Times it had already reflected on the “sad” dilemma management faced in relation to not apprising Ms Cullen of the pathology findings.
“In accordance with the procedure, findings were only shared after the investigation report had been completed and had been sent to the Dutch healthcare and youth inspectorate.
“Special attention should be paid to the inevitable dilemma between conducting a careful and thorough investigation on the one hand, and, on the other hand, honouring the patient’s wish to be quickly informed of any (new) findings.”
Mr Cluskey responded: “Just because they ‘reflected’ on it internally at some point and found that their decision was ‘sad’ does not mean it was acceptable.”
One year on from Adrienne’s death, the incident shows nothing has changed in the ethos of the hospital, despite promises of greater openness, he said.
“Because there have been no changes at the top, and no accountability at any level, it is the same as it was the day in 2011 when Adrienne was unfortunate enough to walk through its door.”
The hospital spokeswoman said that since Ms Cullen’s death, it had decided it would “put [the] wishes of patients, in appropriate cases, in the future more into the heart of the discussion and decisions to be taken”.
