A doctor investigating surgical errors at a Windsor, Ont., hospital has urged the province to overhaul the way pathologists diagnose disease.
Dr. Barry McLellan, Ontario's former chief coroner and CEO of Sunnybrook Health Sciences Centre in Toronto, wants the overhaul finished in the next eight months.
He made the recommendation Wednesday in a sweeping review of three Windsor-area hospitals.
Health Minister Deb Matthews said Malcolm Maxwell, CEO of Grand River Hospital in Kitchener, will oversee the implementation of the recommendations, starting immediately.
"We will also be moving forward to develop provincial standards and guidelines that will ensure high-quality pathology services for all Ontarians," Matthews said.
She said the revelations about surgical errors in Windsor were part of the motivation for the Excellent Care for All Act, which requires that all errors be reported directly to hospital administrators.
The review led by McLellan found serious concerns with the hospital's error-reporting policy and was particularly critical of the work of one pathologist, Dr. Olive Williams.
Williams was suspended after Hôtel-Dieu Grace Hospital admitted that surgeon Dr. Barbara Heartwell removed the breast of a woman who did not have cancer.
Heartwell blamed the mistaken mastectomy on an error in Williams' pathology report.
'I have never been contacted by this government, or by any health-care professionals to ask what happened to me or my side of the case.'— Janice Laporte, victim
McLellan recommended Heartwell's operating privileges be reinstated.
Through her lawyer, Heartwell said she is off work recovering from a horseback riding injury but plans to return to the operating room.
The investigators, who reviewed 6,700 pathology cases, roundly criticized Williams and recommended the Ontario College of Physicians and Surgeons reassess her in case she decides to return to practising in Ontario.
Williams is currently suspended.
At a news conference Wednesday afternoon, Warren Chant, Hôtel-Dieu Grace's chief executive officer, said the hospital "embraces" all the recommendations.
Chant said the hospital will review the report and the findings of its own internal report "to determine how best to implement the recommendations and work with the facilitator over the next several months."
'I am not a statistic'
The investigators reviewed thousands of documents, visited the hospitals 12 times and interviewed 75 individuals, but Janice Laporte told CBC News she wasn't asked anything.
"I have never been contacted by this government, or by any health-care professionals to ask what happened to me or my side of the case," said Laporte, whose breast Heartwell removed by mistake in August 2001.
"If it wasn't for you people, the media, my case would never have been brought forward."
Laporte said she grew increasingly frustrated and angry as she listened to the 19 recommendations in the report.
"I am not a statistic," she said from her home in Sarnia, Ont. "I am a real person. I have real feelings and real emotions.
"I'm so disappointed that this government feels like I'm just another number."
While the report comes down heavily on errors in pathology work, in Laporte's case, Williams was not involved.
Laporte said she believes the report does not hold her surgeon, Heartwell, responsible for her actions.
"I'm so outraged about that," Laporte said.
"She has admitted to two mistakes, two major mistakes and yet they are going to let her do surgery without any kind of restrictions?"
Digital imaging recommended
The report gives the province until March to establish a provincewide quality assurance system for pathology, based on standards and guidelines.
The report also recommended implementing digital imaging in pathology diagnostics, so the same slides can be seen by several physicians in different locations.
One of the key recommendations in the 74-page report is that all pathology work in the Windsor-Essex region be centralized at Windsor Regional Hospital to improve the quality of diagnostics.
It also recommended pathologists in the Windsor area consult with one another, and in cases of neuropathology and hemopathology, work with the London Health Sciences Centre.
The report also criticized Hôtel-Dieu's error-reporting policy, saying most physicians were unaware of how to report errors or near misses.
Hours before the release of the report, Dr. Allan Forse, chief of surgery at Hôtel-Dieu, announced his resignation, effective Sept. 1.
Dr. Gary Ing, the hospital's chief of staff, would only say there were "personal and professional reasons" for Forse's decision.Read the full report, which involved reviewing 6,700 pathology reports.