CREAGHAN REPORT; PART ONE; PROBE INTO DISGRACED PATHOLOGIST DR. RAJGOPAL MENON; EERIE PARALLELS TO CHARLES SMITH TRAVESTY;

"MENON IS NOT THE FIRST PATHOLOGIST WHOSE WORK HAS COME INTO QUESTION, EITHER IN COURT OR AT A PUBLIC INQUIRY IN CANADA.

IN NEWFOUNDLAND, AN INQUIRY INTO HUNDREDS OF MISREAD TISSUE SAMPLES HEARD TESTIMONY THAT POINTED TO SYSTEMIC PROBLEMS IN THE PROVINCE'S CENTRAL PATHOLOGY LAB. THE INQUIRY COMMISSIONER, JUSTICE MARGARET CAMERON, WILL ISSUE HER REPORT EARLY NEXT YEAR. A CLASS-ACTION LAWSUIT ON BEHALF OF THE PATIENTS AFFECTED IS NOW UNDERWAY.

IN MANITOBA, IT WAS REPORTED THIS MONTH THAT A WOMAN'S MASTECTOMY MAY HAVE BEEN UNNECESSARY AND SEVERAL OTHER PATIENTS WHOSE BIOPSIES WENT MISSING RECEIVED INCOMPLETE DIAGNOSES. ANOTHER PATHOLOGIST WAS PUT ON LEAVE AT THE END OF MARCH AFTER CONCERNS WERE RAISED ABOUT THE ACCURACY OF HIS TESTS.

AND IN ONTARIO, A HIGHLY CRITICAL REPORT THIS FALL CITED THE "WOEFULLY INADEQUATE" TRAINING OF PATHOLOGIST DR. CHARLES SMITH WHOSE FINDINGS HELPED LEAD TO HOMICIDE CHARGES AGAINST PARENTS AND CAREGIVERS, MANY OF WHICH WERE UNWARRANTED.""

CANWEST REPORTER KEN MEANEY:

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the report of the Public Inquiry into the work of New Brunswick pathologist Dr. Rajgopal Menon, released yesterday, raises some eerie parallels to Dr Charles Smith -especially the conclusion that he should have been fired several years ago.

That point is made clear in the CANWEST story by reporter Ken Meaney, which ran yesterday under the heading "N.B. pathologist should have been fired in 2005: Inquiry."

"A public inquiry into the work of a New Brunswick pathologist says it should have been clear that Dr. Rajgopal Menon should have been fired, because of problems with his work, two years before he was suspended," the story begins.

"Justice Paul Creaghan's report, issued Wednesday in Miramichi, N.B., found Menon's work was "unsatisfactory in terms of both attention to his duties and to the level of his performance," the story continues.

""By early 2005, it was apparent that Dr. Menon should have been terminated," Creaghan said. "But the commission found there was no program of quality assurance in place" to address problems in his work.

Menon, 73, worked at the Miramichi Regional Health Authority pathology lab from 1995 to 2007 when he was suspended after an investigation raised questions about prostate and breast cancer cases he handled - an audit of 227 biopsies conducted in 2004-05 found 40 were incomplete and seven were incorrect as they indicated patients had no cancer when, in fact, they did.

Creaghan ultimately faulted both the Miramichi Regional Health Authority and the Department of Health for failing to ensure quality control in the lab, for not properly peer reviewing Menon's work and for inadequately disciplining him.
"To say that we require quality assurance and then walk away ... was simply not an acceptable position," he said.

He recommended that the task of auditing the performance of laboratories be delegated to the New Brunswick College of Physicians and Surgeons under a system similar to Saskatchewan and funded by the province.

Without quality control in hospital labs, "this problem is going to happen again. I don't know when, but it will happen again," he said.

Menon came to the attention of the College of Physician and Surgeons after the family of a patient said he had attributed part of the cause of the woman's death to heavy smoking.

The woman, however, was not a smoker.

A class-action suit on behalf of 50 of Menon's patients is underway against the Miramichi Regional Health Authority.

Creaghan said his report does not assign blame or make recommendations on compensation "or actionable recourse that some people might have."
"That's beyond my purview. I'm specifically precluded from doing that," he said. "I make no mention of the pending class-action suit. I have no business with that."

In his own testimony at the inquiry, Menon disagreed with the conclusions of the audit of his work.

He apologized to his patients, but also blamed the incomplete reports on his heavy workload and staffing issues.

Menon was present for the release of Creaghan's report, telling the commissioner he did not address the role of hospital administrators and "the quality of their training."

Creaghan, however, noted the report found there was "complete confusion (at the executive level) with respect to who was responsible to do what," and said the report clearly puts the onus on CEOs to ensure quality control.

Among his recommendations, Creaghan said:

- Pathologists must be recognized for their important role and be properly paid for it;
- He said measures must be taken to ensure adequate quality assurance in hospital labs;
- Responsibility for performance of hospital labs rests with the CEO of the health authority;
- Hospital labs must operate under a program that emphasizes patient safety and not risk management.

"I don't think pathology and pathologists have been given the proper credit for the role they play . . . And I hope this inquiry will do something about that," Creaghan said.

Donald J. Peters, president and CEO of the Miramichi Health Authority, said Wednesday the board will carefully review the recommendations.

"We are committed to quickly move forward in collaboration with the Department of Health, the College of Physicians and Surgeons of New Brunswick as well as with our medical and laboratory team to ensure the best possible laboratory services are provided."

Menon has had his medical licence suspended, but he's fought back with a civil lawsuit against the health authority.

Menon is not the first pathologist whose work has come into question, either in court or at a public inquiry in Canada.

In Newfoundland, an inquiry into hundreds of misread tissue samples heard testimony that pointed to systemic problems in the province's central pathology lab. The inquiry commissioner, Justice Margaret Cameron, will issue her report early next year. A class-action lawsuit on behalf of the patients affected is now underway.

In Manitoba, it was reported this month that a woman's mastectomy may have been unnecessary and several other patients whose biopsies went missing received incomplete diagnoses. Another pathologist was put on leave at the end of March after concerns were raised about the accuracy of his tests.

And in Ontario, a highly critical report this fall cited the "woefully inadequate" training of pathologist Dr. Charles Smith whose findings helped lead to homicide charges against parents and caregivers, many of which were unwarranted."

Harold Levy...hlevy 15@gmail.com;