An independent review of the Covid-19 vaccination programme at the Coombe hospital has found that a consultant brought some vaccine home and administered it to two family members.
Earlier this year, the Coombe Women & Infants University Hospital apologised for the vaccination of 16 family members of the employees at the hospital on 8 January.
An independent review into the controversy was carried out by Brian Kennedy SC.
After discussing the findings, the hospital board said: "Despite the mitigating factors, and the overall success of the vaccine programme, the Board is disappointed that 16 family members were vaccinated with leftover vaccines. This should not have happened.
"We are also concerned that in the case of one family, two vaccinations occurred offsite. Again, this should not have happened."
The board said guidelines "in respect of the priority list for vaccination were followed at all times, save for 16 doses administered to the families of some hospital staff on the night of Friday 8th January".
It said: "These doses were administered after hospital personnel formed the view that no other frontline staff were immediately available for vaccination.
"The Clinical Guidance then available stated that leftover vaccines were to be discarded, although the subsequent Sequencing Guidance, which post-dated the first round of vaccinations at the hospital, stated that no doses were to be wasted."
It said: "The 16 vaccinations were administered across eight families who otherwise would not have been eligible to receive the vaccinations that evening.
"Of the 16 recipients, nine were over 70 and the remaining seven were of varying age.
"In the case of one family, two vaccinations occurred offsite.
"No vaccine was wasted," it added.
It said the review "identified other, alternative options that may have been available in respect of other recipients, and the difficulties which may have applied to these groups".
A statement today said decision making and options were impacted by a range of factors:
- evolving guidance regarding the use of leftover vaccines and the number of vaccines which could be used per vial
- there was nothing contained in the guidelines on the preparation of a standby list
- the absence at that time, of a centralised IT software solution, required manual management of the process (to include potential recipients) until the HSE's Covax software system subsequently became operational
- peaks and troughs in vaccine attendance creating less certainty about how many vials of vaccine to open and dilute at any given time
- a pressured environment, compounded by long hours, Covid related staff absences and the challenge of implementing this vaccine for the first time alongside normal functioning of the Hospital.
The review found that following a conversation between "Consultant C", "Consultant B" took the remaining vaccine home with them and administered it to two family members on the evening of 8 January.
"Consultant B" said they understood that "Consultant C" gave them permission to take the vaccine home.
The report said "Consultant B" completed the relevant forms with the family members.
The report went on to say that it does not appear that any of the individuals present on the evening apart from "Consultant C" were aware that Consultant B took vaccines home and vaccinated family members at home.
Meanwhile, the report said "Consultant C", who went home to collect their family members, indicated to them that they would not necessarily be vaccinated and that that would depend on whether any vaccine remained when they returned.
"Consultant C" told Brian Kennedy SC that eligible individuals continued to be vaccinated beyond 9pm and emphasised that had any other eligible vaccinees arrived after that stage, they would have been vaccinated in preference to family members.
The report found that some of the staff members left the hospital to collect their family member or members, while other family members arrived to the hospital by other means.
The various family members arrived at the hospital and were apparently vaccinated, according to the hospital's vaccination records, between 9.40pm and 10.10pm, it said.