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Consultants group described operations as surgical ‘never event’ that happened because of failings in procurement processes and safety checks
The Irish Hospital Consultants Association (IHCA) has described a surgeon’s use of unauthorised and wholly unsuitable devices in children’s spinal procedures as ‘entirely preventable’ if proper procedures were in place at the hospital in which he worked.
This week a HIQA report found that the implantation of unauthorised springs in three children at Temple Street Hospital was ‘wrong’ and ‘should not have happened’.
The review could not find any evidence that written approval was given by any senior manager in Children’s Health Ireland (CHI) for the clinical use of the springs. No evidence of ethical approval was found either.
The HIQA report was highly critical of the policies and procedures at Temple Street. It said that, since the establishment of Children’s Health Ireland (CHI) as the body overseeing three children’s hospital sites in Dublin in 2019, changes to organisational structures led to unclear lines of reporting, accountability and oversight across the organisation.
Yesterday the IHCA issued a response which described the spinal procedures as a surgical ‘never event’ that emerged as a result of ‘numerous failings in the hospital’s procurement processes and safety checks’.
The IHCA statement references that ‘surgeon A’ who carried out the procedures told HIQA that he believed the springs were made of stainless steel.
However, the HIQA report found that the unauthorised springs used in the surgeries were made of unalloyed spring steel – a material that is prone to rust and corrosion.
HIQA reviewed emails between the surgeon and the company from whom he sourced the springs, which referenced a product catalogue number. When HIQA officials looked up that number in the company’s product catalogue, they found that it referred to compression springs that were described as ‘unalloyed spring steel’, not stainless steel.
HIQA’s full statement is below.
‘The Irish Hospital Consultants Association (IHCA) recognises the deep distress and hurt caused to the three children and their families, as detailed in the recent HIQA report on the governance of implantable medical devices at Children’s Health Ireland (CHI).
The report highlights serious system-wide governance failures at CHI, particularly at Temple Street, where consultants were working under intense pressure with high patient care needs and workloads with inadequate support.
It is within this environment that a surgeon, acting with good intent and in the absence of effective structures, endeavoured to provide innovative care to children.
These were children with complex life-limiting conditions—children who, without intervention, faced extremely poor outcomes and suffering.
As indicated by the HIQA report, at the time the surgeon believed the devices to be medical-grade stainless steel, CE marked as suitable for use as surgical implants.
Due to the numerous failings in the hospital’s procurement processes and safety checks, this surgical “never event” happened. This was, and should have been, entirely preventable had proper policies and procedures been adhered to at the hospital.
HIQA itself recognised these actions as a well-meaning effort to prolong the lives and improve the quality of life of these patients. Nonetheless, this situation underscores the urgent need for robust governance systems to ensure both patient safety and clinical accountability.
While individual accountability is essential, consultants do not work in isolation. They depend on functioning, transparent management structures and appropriate clinical supports. Failures in these systems increase the risk of poor outcomes, despite the best efforts of medical professionals.
The IHCA supports the recommendations issued by HIQA and calls for their swift implementation, both within CHI and nationally. At the same time, we urge that future regulation continues to allow space for safe, ethically sound innovation that benefits patients with curative treatments and/or improves their quality of life, especially those with the most complex and challenging needs.
We hope the new National Children’s Hospital will provide a much-needed reset—fostering a culture of strong governance, clinical excellence, and compassionate innovation that ensures the highest standard of care for our most vulnerable children.
The IHCA is committed to working collaboratively and constructively to ensure that the very highest levels of clinical governance are embedded across all services in the newly established children’s hospital, which is due to open shortly. We will continue to work proactively with all stakeholders to ensure every support is provided to clinical directors in delivering the highest standards of patient care in our hospitals.’
See also this week’s ‘Comment’ by Terence Cosgrave.
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