An investigative report into the pathology service and the symptomatic breast service at University Hospital Galway (UHG) has sharply criticised the lack of formal arrangements between UHG and Barrington's Hospital in Limerick, which lead to the misdiagnosis of a patient's breast cancer.

The report, which was published yesterday, found that the lack of formal arrangements for multidisciplinary case reviews between UHG pathologists and Barrington's Hospital staff meant that any opportunity to correct the interpretative errors in Ms A's case was lost.

It also found that the agreement between UHG, which was paid for the lab services it provided to Barrington's and the Limerick hospital, was based on an informal arrangement between clinicians, with no formal governance arrangements overseeing the service.

Bridget Howley, General Manager at UHG, yesterday welcomed the report's publication and again apologised to Ms A and her family for the errors.

Ms Howley also apologised to patients for the distress caused to them by shortfalls in the communications process. She said that during the course of the investigation initiatives were taken in UHG to improve the quality of the laboratory diagnostic service. She said the hospital has accepted the report's recommendations and is in the process of implementing its recommendations.

The measures being taken include developing service level agreements with other hospitals; strengthening the clinical governance system; enhancing locum recruitment procedures; developing patient advocacy structures, and improving overall technical standards and quality.

Professor Martin Cormican, Clinical Director, Laboratory Services said, "The team in the hospital who have been dealing with this investigation would like to say a very sincere thank you to the many patients and families we have talked to who have shown extraordinary patience, generosity and understanding for the shortcomings of the service at a time when they were entitled to feel disappointed and hurt. UHG is committed to using the learning from this to drive continuing improvements to services at the hospital for the benefit of patients and their families."

The review charts the history of errors in Ms A's case. It states that cells sent by Ms A's consultant for analysis on two separate occasions were misread as benign, delaying her breast cancer care by over a year.