PATIENTS ARE being put at potential risk at a number of smaller hospitals across the State as a result of the failure of the Health Service Executive to implement the findings of a report published two years ago.
This is one of the findings by the Health Information and Quality Authority (Hiqa) following the publication yesterday of the results of its investigation into the safety of services at Mallow General Hospital.
The authority said it was regrettable it had to conduct the Mallow investigation, which would have been unnecessary had the HSE implemented the recommendations of a similar report looking into the safety of services at Ennis General Hospital.
That report was published in April 2009, and recommended the HSE look at other similar-sized hospitals to see if they were providing safe services, and to ensure they were not, for example, conducting complex surgery on low volumes of patients without back-up facilities such as intensive care beds. The investigation into Mallow hospital proved this had not happened.
Yesterday’s report was damning of the HSE for failing to disseminate the learning from the Ennis report. It said this failure to learn from a previous report “by the statutory regulator” and spread its findings for the benefit of patients across the healthcare system was of “utmost concern”. It represented a “serious failing of corporate governance which potentially placed, and continues to place in some parts of the country, patients at risk and must be learned from and avoided in the future”.
The report also said it wasn’t until after Hiqa announced its investigation into Mallow – 16 months after the Ennis report was published – that the HSE provided evidence of any systematic approach to assessing and addressing issues in other similar-sized hospitals. In September 2010, the HSE wrote to Hiqa identifying other hospitals as being in Navan, Roscommon, Dundalk, Portlaoise, Loughlinstown, Nenagh, Mallow, Bantry and St John’s in Limerick. A number of these hospitals were still receiving 24-hour emergency attendances “with insufficient measures outlined by the HSE as to how clinical risks were being identified and managed”, the report said.
Hiqa wrote to the HSE in November 2010 asking it to clarify what measures were in place to mitigate these risks. It got a report from the HSE in February 2011 indicating that many of the actions to manage current risks for patients would be “happening some time in the future”.
But the HSE did tell Hiqa it planned to convert the 24-hour emergency departments at Navan, Loughlinstown, Mallow and Bantry hospitals to minor-injury units. It also confirmed there were plans to cease acceptance of complex emergency cases at Roscommon, Mallow, Bantry and Loughlinstown hospitals.
Hiqa’s report said the HSE’s recent letter, overall, indicated that “by early 2011 the risk mitigation plans for each site had yet to be completed or implemented by the HSE. This is not satisfactory and consequently there is a potential for patients receiving acute services in such hospitals to continue to be at risk”.
The HSE said last night a robust process to ensure the full implementation of all reports had been established.