“This is a damning report and it is clear from the findings that many lessons need to be learned and changes made to ensure that such events do not happen again in Irish hospitals ... consultants [should] work in teams with clear clinical leaders who will ensure that individual clinical practice is in line with best practice,” the Minister for Health said about the findings that unnecessary surgeries were performed on multiple vulnerable Irish patients.
This statement was not – as you may think – made by Minister Jennifer Carroll MacNeill in the context of last Friday’s audit report on surgeries carried out on children with developmental dysplasia of the hip (DDH) in Children’s Health Ireland (CHI) hospitals at Temple Street and at Crumlin, both Dublin, and in the National Orthopaedic Hospital at Cappagh (NOHC), also Dublin.
Rather, it was a statement made in March 2006 by Mary Harney, then minister for health regarding the shocking findings of Judge Maureen Harding Clark’s inquiry report.
That investigation into the scores of unnecessary hysterectomies carried out at Our Lady of Lourdes hospital in Drogheda, Co Louth, exposed a culture of deference to senior consultants, inadequate oversight and poor mechanisms for reporting and addressing potential medical malpractice.
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The Dr Michael Neary scandal laid bare major weaknesses in the State’s healthcare system as a whole, particularly in clinical oversight, transparency and accountability.
Sweeping reforms followed this, and other controversies, including: the creation of the Health Information and Quality Authority (Hiqa) to set healthcare standards, monitor compliance, and ensure quality care; the restructuring of the Irish Medical Council; the formation of the National Clinical Effectiveness Committee (NCEC) to oversee national clinical guidelines and audits; and the implementation of a national policy on open disclosure to encourage honest communication with patients following adverse events.
At the core of reforms to strengthen patient care and safety was the introduction of a clinical directorate system in the HSE. This model embedded clinicians in leadership roles, giving them formal decision-making authority and, supposedly, creating clearer lines of accountability.
It represented a huge cultural shift: senior doctors were now expected to not only provide care, but take shared responsibility for the governance and quality of services.
The aim of all these reforms, and others, was to build a safer, more accountable, and patient-focused healthcare system. Yet, more than 20 years later, we are again reading a report that demands questions about whether there were serious failings in clinical governance involving multiple patients.
The proportion of pelvic osteotomies to treat developmental dysplasia of the hip in young children undertaken at CHI at Temple Street and Cappagh NOHC (among the audited sample cases between 2021-2023) was so high and out of line with international criteria that last week’s audit report called for an extended review to go back to 2010.
The report found that close to 70 per cent of surgeries did not meet the threshold for surgery, meaning they may not have been necessary. The report recommends that every case is offered a review. It also noted some medical records from cases it selected were missing and that an experimental surgical technique was used in some surgeries without proper informed consent.
The HSE said it has already started to implement new safeguards as recommended by last week’s review report, including cross-site preoperative multidisciplinary review meetings and the creation of an expert panel to establish standardised criteria for this type of surgery.
But it has to be asked why weren’t such safeguards already in place? Why was there no co-ordinated approach across the sites under CHI carrying out this surgery, given the body was created to merge the national children’s hospitals before the move to the new national children’s hospital?
Why and how was this “variation” in surgical practice allowed to continue for potentially so long (assuming the findings going back to 2010 will be similar to 2021-2023) and in so many patients?
What happened between September 2023 when the protected disclosure was made, and last July when this audit was commissioned?
Were concerns raised earlier by other staff? If so, at what level and how were they addressed?
The pelvic osteotomy cases audited at Crumlin were found to be warranted and in line with international standards. Was this discrepancy noticed by anyone? Were no inter-site comparisons made? Was there no routine audit?
Continuous review and audit of clinical practice, with a focus on improvement and applying the lessons learned, should be the cornerstone of any high-quality healthcare service. Audits can uncover unwarranted variation in clinical practice, which can lead to potentially avoidable poor patient outcomes.
Yet in Ireland there remain serious gaps in how and where clinical audit is performed and an often touchy, secretive approach to disclosure and reporting.
The concerns about children’s pelvic osteotomy surgeries came to light not through standard audits or a report of poor outcomes, which is the basis for commissioning many healthcare reviews, but via protected disclosure by a whistleblower. Just like the Neary affair.
As I wrote following the publication of the damning Hiqa governance review on the use of non-CE marked springs in surgery at CHI at Temple Street report last month, we have a complex and confusing web of governance and accountability in the Irish hospital system. When no one is clearly responsible, no one is truly accountable.
We regularly hear about how essential robust clinical governance is to a healthcare system. But it’s one thing putting protections and systems in place; it’s another ensuring these actually work.
Major failures are usually followed by reform, but reforms often fall short in practice and can be bogged down by confusion, resistance or fear. When changed structures are announced and new roles with increased responsibilities are created, filled and paid, who ensures these are actually functioning effectively, being supported adequately and those commitments are being fulfilled?
Sometimes healthcare staff simply leave when they realise that nothing is being done to address alarming issues that are placing patients and staff themselves at unacceptable and potentially avoidable risk.
Last week HSE chief executive Bernard Gloster spoke of how “putting in place a mechanism to ensure this kind of variation can’t recur is central to our next steps, and we will be working with everyone to ensure that this can’t happen again”.
Yet we must ask: how can we still be listening to promises that this can never happen again two decades after the Neary scandal?
Priscilla Lynch is clinical editor of the Medical Independent and a freelance healthcare reporter who completed a fellowship in health innovation journalism with the International Centre for Journalists last year
The DDH Parent Information Line is open for families who have queries following this audit’s publication: Freephone 1800 807 050 (or 353 1 240 8706 from outside Ireland)
