July 2022
Patient safety concerns raised at Children’s Health Ireland (CHI) hospital group following a “particularly serious” surgical incident.
September 2022
Second patient safety incident reported.
November 2022
A consultant ceases doing complex spinal surgery on children with spina bifida.
The then minister for health Stephen Donnelly tells the Dáil a specific complex procedure, known as kyphectomy, had been paused by the surgeon and patient safety protective measures were put in place by CHI. He said this included measures such as working under additional supervisions and restricting certain clinical duties.
The Department of Health was informed that two serious patient safety incidents had occurred in Temple Street.
Department of Health advised that an internal clinical review of outcomes of complex spinal surgery for spina bifida patients at Temple Street was initiated after concerns were raised by the spina bifida multidisciplinary team that comprises paediatricians, nurses, physiotherapists and an occupational therapist. This team raised concerns about surgical outcomes.
Department of Health told CHI had also commissioned an external review.
July 2023
External review, carried out by the Boston Children’s Hospital, is completed. HSE’s chief clinical officer determines that an additional, wider and externally-led review is needed.
August 2023
An additional patient safety concern was reported by CHI concerning the use of non-CE marked spring implants in three surgeries carried out.
September 18th, 2023
CHI says HSE has commissioned UK expert Selvadurai Nayagam to lead an external review of elements of the paediatric orthopaedic surgical service at Temple Street.
CHI says a primary focus of this review will be the clinical care provided by an individual consultant at Temple Street. CHI says the consultant concerned was not carrying out surgeries and had been referred to the Medical Council.
The hospital group says review “arises from very serious concerns identified by CHI since last year relating to poor surgical outcomes in spinal surgery at Temple Street, the use of a certain spinal surgical technique and the use of unauthorised implantable” devices.
CHI says reviews it commissioned had examined the care provided to 17 children who had complex spinal surgery Temple Street. It says “one child sadly died since, and a number of other children suffered significant post-operative complications”.
Donnelly separately directs the Health Information and Quality Authority (Hiqa) to carry out an independent review at CHI on the use of the non-CE spring implants during spinal surgery in Temple Street and to look at the controls, oversight processes and governance within the hospital group on the use of surgical implants.
The then taoiseach Leo Varadkar says: “The more and more I read about it, the more concerned I am and the more bothered I am.”
“If you have a child awaiting surgery, you think if they get the surgery that is going to make them better, not worse. It seems that some of these surgeries were performed incorrectly and children suffered and were harmed as a result. That is unbelievably serious.”
