There must be a “full public inquiry” into spinal surgery for children with scoliosis and spina bifida after a report showed controls at a Dublin paediatric hospital did not protect children from “the risk of harm”, two advocacy groups have said.
On Tuesday, the Health Information and Quality Authority (Hiqa) published a report on the use of unlicensed springs in three children who required spinal surgery at Dublin’s Temple Street Children’s Hospital between 2020 and 2022.
According to the watchdog, the use of such springs as surgical implants in operations at the hospital was “wrong”, while failures in controls meant “children were not protected from the risk of harm”.
The springs were of “non-alloyed spring steel” which were not suitable for implantation because they corrode when in contact with moisture.
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In a joint statement following publication of the report, the Spina Bifida & Hydrocephalus Paediatric Advocacy Group and the Scoliosis Advocacy Network said families have been “ringing the alarm bell for years” on the issue.
“While the Hiqa review is comprehensive, its scope was too narrow. It shines a light on one appalling failure – but behind it lies a wider culture of dysfunction, disregard for safety, and systemic neglect that spans services and sites,” the groups said.
“This review must be the beginning, not the end. A full public inquiry is now essential. It is what the families at the centre of this have requested, and it must begin with meaningful input from the advocacy groups who have been raising the alarm for years.”
Liz McMahon and David Ryan, the parents of Luke Ryan, one of the three children who was implanted with an unapproved spring, said their son was “failed” by the paediatric services at CHI.
“As parents, we could never have contemplated that an experimental non-medical grade spring would without our knowledge or consent be placed in our child in an Irish hospital. Such an event was a complete breach of parental trust by CHI,” they said.
“Not surprisingly, that spring device then disintegrated inside Luke, resulting in the necessity for further surgical intervention. Luke’s healthcare pathway was anything but the path that he should have experienced.”
Lucy Nugent, the newly appointed chief executive of Children’s Health Ireland (CHI), apologised to the families affected, describing what happened as “unacceptable”.
“We are deeply sorry that these children, young people and families did not get the care they deserved,” she said.
Ms Nugent said the hospital group “sincerely regrets and apologises” for the risks posed to the three patients who had the non-CE mark springs implanted.
Speaking in the Dáil on Tuesday afternoon, Taoiseach Micheál Martin said it is “beyond comprehension” that unauthorised springs were used in Temple Street.
However, he ruled out holding a public inquiry, stating “these inquiries last years. They don’t give victims closure, they cost millions”.
Minister for Health Jennifer Carroll MacNeill said she was “shocked by every element” of the report.
She said it was unacceptable a “rogue surgeon engaged in this way, however well intentioned”.
“We have a series of processes that may have been there but were not followed. That’s a problem for him, but it’s a much, much bigger problem for CHI and for the governance of the hospital and for CHI more broadly,” she told RTÉ Radio 1’s News at One.
HSE chief executive Bernard Gloster said what happened was wrong and unacceptable.
“Given the role of the HSE in funding CHI, I want to offer a sincere and unequivocal apology to the children and families affected by these issues,” he said.
