All well-run organisations make mistakes, but they also respond quickly and learn from these errors. CervicalCheck, Dr Gabriel Scally noted in his landmark report on the screening service last year, was "doomed to fail" because of its many structural, governance and communications deficits. And fail it did, spectacularly; a year on from the original controversy over a botched audit, fresh errors are still coming to light in its communications with women.
But what of the wider Health Service Executive (HSE), which has, since the CervicalCheck controversy, committed itself wholeheartedly to open disclosure? What are we to make of new figures that show most serious incidents in the health service are not reported upwards, or investigated, within target time-frames?
The fact the HSE is so far off meeting its own targets in relation to reporting and investigating things that go wrong... is extremely worrying
Just 2 per cent of investigations into serious incidents were completed by the HSE last year within the required four months, according to the figures provided to Fianna Fáil. Meanwhile, 35 per cent of serious incidents, which involve harm or death to patients, were notified within 24 hours, as required, to a senior, accountable member of staff.
Half of all incidents are entered into the HSE’s electronic database within the required 30 days. Whether these incidents were preventable or not, they need to be investigated so repeat events can, if possible, be avoided. Prompt inquiry also ensures complaints and litigation can be dealt with more quickly.
Hospitals and other centres of healthcare delivery are busy places, and it may not always be possible for staff to report incidents immediately. In an organisation as large as the HSE, there are clear difficulties in ensuring uniform practice across the system. But the fact the HSE is so far off meeting its own targets in relation to reporting and investigating things that go wrong, and appears to have relaxed a target on the carrying out of mandatory investigations, is extremely worrying. It also appears to show it is still some way off becoming a properly patient-focused, transparent organisation.