The Health Information and Quality Authority today published the Report of the investigation into the quality and safety of services and supporting arrangements provided by the Health Service Executive at Mallow General Hospital.

The Board of the Authority approved the Report and authorised it for publication.

Speaking at the launch of the report, the Authority’s Director of Healthcare Quality and Safety, Jon Billings said “This investigation has revealed that while longer-term improvements are in train, the response of the Health Service Executive (HSE) to key recommendations from the Authority’s investigation report into Mid-Western Regional Hospital Ennis, published in April 2009, has been slow and inconsistent, with certain actions only happening relatively recently in response to enquiry from the Authority.

“In Mallow General Hospital (MGH), this has resulted in a service based on historic practices continuing with insufficient action at a local, regional or hospital group level to identify and anticipate any clinical risks to acutely ill patients and manage these in advance of planned longer-term change. The investigation found that the seniority of medical staff available on site outside core hours in Mallow General Hospital was not adequate for a hospital open to emergencies 24 hours a day. This has subsequently been addressed by the HSE. In short, the safety and quality of the service provided to patients was dependent on the willingness of local clinical staff at MGH, rather than a resilient and reliable system of care.”

As with the Authority’s investigation into Ennis, the volume of major complex surgery is relatively low and the numbers of cases is set to reduce further and in the Authority’s view, measures must be taken to ensure outcomes for patients meet expected levels and patients with complex surgical needs should be treated in hospitals that can appropriately deal with their needs.

Reflecting on the future for Mallow General Hospital, Jon Billings said: “Mallow General Hospital should have an important future serving its community. But this must be as part of a wider hospital network which ensures patients requiring specialist and complex care receive it in a centre with the arrangements in place to do so safely and reliably, while allowing the majority of patients to continue to be diagnosed and treated locally.”

“The fact that the Authority found it necessary to invoke its powers to investigate services at Mallow General Hospital indicates a fundamental and very concerning deficit in our health system, namely the ability to learn. The investigation report found that the HSE is implementing a range of programmes that will benefit patients significantly, but has not balanced implementing medium to longer-term solutions for the safe configuration of hospital services with identifying, managing and addressing clinical risks for acutely ill patients that can be inherent in small stand-alone hospitals.”

The report also found that the national recommendations made in the Ennis Report by the Authority, which explicitly signalled the need for urgent action in this respect, only began to be addressed by the HSE in a systematic way from the summer of 2010, 14 months after the publication of the Ennis Report, and only after prompting from the Authority’s enquiries.

“In the context of the clearest recommendations, which specified the governance and reporting mechanisms necessary for successful implementation, this represents a serious failing of corporate governance. This is not acceptable to the Authority and has resulted in the Authority issuing 20 new recommendations, 10 of which relate to the governance and accountability of the HSE.”

In conclusion, Jon Billings said: “The HSE, the Department of Health, clinical leaders and managers need to reflect on the findings of this report with a view to ensuring their respective roles in and accountability for planning, delivering, receiving and funding healthcare services delivers system-wide learning from adverse findings in one part of the service for the benefit of all service users.”

The Authority will evaluate the HSE’s implementation of the recommendations from this investigation alongside its compliance with the National Standards for Safer Better Healthcare, once mandated, and publicly report on our findings.

ENDS

Further Information: 

Marty Whelan
Head of Communications and Stakeholder Directorate
01 8147481 / 086 2447623 or email mwhelan@hiqa.ie

Notes to the Editor: 

• In April 2009, the Authority published the Report of the investigation into the quality and safety of services and supporting arrangements provided by the Health Service Executive at the Mid-WesternRegional HospitalEnnis.
  The report contained a number of national recommendations aimed at creating an impetus for systematic review of clinical services in hospitals similar to Ennis.

• The Authority was concerned that there were hospitals providing care to acutely ill patients where the volume of patients is too low or the depth of clinical staffing cover is insufficient for this to be done reliably and safely. The Authority sought assurances from the HSE as to how the national recommendations from the Ennis Report had been implemented. The Authority did not receive a satisfactory response.

• It was in this context that the Authority developed specific concerns about aspects of the care provided at Mallow General Hospital, following receipt of confidential information about the types of patients being treated in that hospital. This raised concerns about the potential risks to the health and welfare of persons receiving health services at Mallow General Hospital which centred on the provision of major surgery, emergency department and critical care services.

• The investigation found that Mallow General Hospital did not have around-the-clock on-site clinical expertise and facilities to safely manage patients with complex clinical needs.

• The Authority highlighted a number of immediate patient safety concerns which came to its attention during the course of the investigation, and requested immediate steps from the HSE to avert further risk of harm to patients. On foot of these requests, the HSE introduced a mandatory policy for Cork University Hospital to accept critically ill patients from Mallow General Hospital.