The Tallaght Hospital Review into why nearly 58,000 adult X-rays were not examined by a radiologist has concluded there were serious delays in reporting results and that two patients had a delayed diagnosis.
The report places the blame for the backlog in the radiology department on the hospital and the Health Service Executive and says 57,921 X-rays were not reported on.
Review chairman Dr Maurice Hayes criticises the hospital for not vigorously seeking more consultants and the HSE for not approving posts in a timely manner.
It notes that a delayed diagnosis was reported in two cases but the review by the hospital of the other 57,921 X-rays found no untoward event, no missed diagnosis and no undetected condition.
The report says there was also a delay in responding to 3,498 GP referral letters for patients to be seen in the outpatient departments.
While no letters were 'unopened', there was confusion between letters, which had been opened and read but not processed and letters 'set aside' because of a lack of appointment slots, with no response to the patient or GP.
The inquiry team says that so far it has been advised that in relation to the GP letters, no serious event has been discovered and no patient appears to have been endangered, although patients had to suffer the worry and anxiety of delayed treatment, or of waiting for an appointment.
By mid-September, 415 patients remained to be seen from the GP referral letter backlog.
The inquiry says the X-ray problems arose from a lack of formal protocols, problems with the IT systems and delays in typing reports.
It also says there were severe systemic weaknesses at management level and in the structures of the hospital board and that the X-ray problems occurred almost from the opening of the hospital in 1998.
The report recommends that extra consultant radiologists be appointed to avoid the same problem occurring.
It says the recently circulated national guidelines on radiology reporting be implemented.