A medical consultant at the Coombe Women and Infants University Hospital took doses out of the hospital to vaccinate family members at home, a review of vaccinations by the maternity hospital has found.
A lawyer asked to investigate the vaccination of family members of staff with leftover doses in January disclosed details of the vaccinations in a report published by the hospital on Thursday.
The report says the master of the Dublin hospital was aware that the consultant - who had been carrying out vaccinations at the hospital - was bringing doses home to administer to the consultant’s family.
The board of the Coombe asked Brian Kennedy SC to carry out an independent review of the decision by the hospital’s master Prof Michael O’Connell to 16 family members of staff.
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As first reported in The Irish Times in January, the initial doses were given to relatives late on Friday, January 8th after Prof O’Connell said doses were left over following vaccinations at the hospital.
The report found that 16 vaccines were administered to one or more family members of eight staff.
The family members vaccinated included two of Prof O’Connell’s children.
Mr Kennedy said that the decision to vaccinate family members “emerged from a relatively short and information conversation” between 11 individuals before or around 9pm that night.
“No one who was present indicated any disagreement, nor have any of those present suggested that they were coerced or pressurised into the decision,” he concluded.
“In that sense, the decision can be characterised as a consensus decision.”
The report concludes that Prof O’Connell “expressed some form of agreement” and several of those present “considered that to be a matter of significance” that a decision had to come from the master or more generally from a person in senior management or a position of authority”.
“Furthermore, if [Prof O’Connell] had not agreed with the decision, as [Prof O’Connell] stated himself, it would not have happened,” said Mr Kennedy.
His report said a doctor, only identified in the report as “Consultant B”, took two vaccine doses home and administered them to two family members after a conversation at the hospital with “Consultant C” - who is Prof O’Connell.
“For their part, Consultant B understood that [Prof O’Connell] gave them permission to take the vaccine home. In an interview with me, Consultant B stated that they would not otherwise have taken the vaccine from the hospital,” Mr Kennedy said in the report.
“For their part, [Prof O’Connell] stated in an interview with me that they agreed that Consultant B could take the vaccine home.”
Asked by Mr Kennedy whether he gave permission to the doctor to take the vaccines home, [Prof O’Connell] “characterized their understanding of the position as being more that if Consultant B… was comfortable to take the vaccine home, they were not standing in their way.
“[Prof O’Connell] stated ‘so if that’s construed as permission, that’s permission’ but further states that they do not recall actually stating that they permitted Consultant B to take the vaccine home.”
Training video
Mr Kennedy asked Consultant B about an online training video for vaccinators which state that “diluted vaccine should not be transported for administration in another location”.
“When asked about this, Consultant B stated that while they watched the relevant online video, they did not recall the reference to the transportability of the vaccine and did not give it any consideration on Friday evening,” he said.
The report said Consultant B did not recall any discussion about the “transportability” of the vaccine on the evening.
The doctor lives relatively close to the hospital and “understood that the vaccine would still be effect if it were transported by car over a relatively short distance,” the report states.
Mr Kennedy said that given Consultant B’s training and knowledge of their family members’ medical history, they were confident that they could manage the administration of the vaccine to them at home.
Medical students
The report also finds that there was “no standby list” of others to be vaccinated in the event of leftover doses but there was no guidance at the time which suggested a requirement for a list.
There was also “no consideration or discussion” on the evening of the excess vaccines that there was the possibility of vaccinating medical students, Mr Kennedy said.
The hospital and in particular Prof O’Connell were not aware that medical students from a university, understood to be Trinity College Dublin, had been told be on standby, the report finds.
Mr Kennedy said that there was a conversation amongst a group of 11 consultants, medics and hospital staff, including Prof O’Connell who met in the vaccination area on the night of January 8th to decide what to do with the leftover doses.
The lawyer found that there was no discussion about the possibility of attempting to identify frontline healthcare workers from other hospitals who had not been vaccinated and asking them to come to the hospital to be vaccinated.
The master later told Mr Kennedy in an interview that he “gave thought at the time to the possibility of seeking to get candidates from the nearest Garda station or fire station”, though he did not state it to the group at the time.
The master indicated that the group was concerned about consent procedures, a lack of knowledge of medical history and whether medical legal cover would be available.
“That being so, [Prof O’Connell] did not raise the possibility with the group,” said Mr Kennedy.
The report found that it was not possible to establish whose idea it was to vaccinate family members but “it may be that the first reference was by one individual to the fact that another individual had an elderly family member or members living relatively nearby”.
In a statement, the board of the hospital accepted that “mistakes were made, not least in the decision to vaccinate family members and, in one case, in the administration of two vaccines offsite. Lessons must and will be learnt to ensure that similar issues cannot recur.”
‘Key actions’
Mary Donovan, chairwoman of the hospital, said the board was “disappointed” that the family members were vaccinated with leftover vaccines.
“This should not have happened. We are also concerned that in the case of one family, two vaccinations occurred offsite. Again this should not have happened.”
She said that the board “takes what occurred extremely seriously and has started a process to address the implications”.
The hospital said that “key actions and measures are being implemented to ensure that such an incident could not occur again and hospital guidelines and protocols will be enhanced.”
Ms Donovan said that the hospital has shared Mr Kennedy’s report with the Minister for Health Stephen Donnelly, the HSE and the Medical Council.
Mr Donnelly, HSE chief executive Paul Reid and other figures in politics and healthcare criticised the decision to vaccinate the family members at a time when only frontline healthcare workers and vulnerable residents in nursing homes had priority for vaccines.
In late January Mr Donnelly sought a full account of what happened with the vaccine rollout at the Coombe from the chairman of the hospital’s board, saying that: “Trust in the vaccine programme is of critical importance and what happened should not have happened.”
Prof O’Connell apologised and said that he made “every effort to prioritise and identify additional frontline workers” for the vaccines on the evening of January 8th but they could not find more so the decision was made to vaccinate family members to avoid doses going to waste.
Prof Deirdre Murphy, head of the department of obstetrics at Trinity College Dublin and a consultant at the Coombe, later told Mr Kennedy as part of his review that almost 40 medical students were overlooked for vaccines on the night they were given to the family members.
Prof Murphy said that the master told her two days after the family members were vaccinated that the hospital was “not in a position” to vaccinate the students.
The HSE has advised that medical students should be vaccinated alongside other health staff during their placements in hospital. Prof Murphy said that at the time of the vaccinations some of the students were working overnight on the labour ward in the Coombe.
