We still do not have a full picture of what exactly transpired at Children's Health Ireland Temple Street University Hospital in Dublin.
The issues at Temple Street, outlined in the HIQA report published this week, relate to one consultant, identified as Surgeon A, and unapproved spinal springs being implanted in three children.
HIQA found that children were not protected from the risk of harm and that while the surgery was well-intentioned, it was wrong. The surgeon remains on leave.
Two more reviews
Surgeon A is also facing a separate independent review, commissioned by the Health Service Executive, on poor outcomes on children's spinal surgeries, the use of a certain spinal technique and the use of those non-alloyed unauthorised springs.
This review led by a consultant in orthopaedics and trauma, Mr Selvadurai Nayagam, Royal Liverpool University and Royal Liverpool Children's Hospitals, has been dealing with at least 19 families, since the review was announced in September 2023.
The review is examining a number of "serious" spinal surgery incidents, including a child who later died.
Children's Health Ireland (CHI) is a HSE-funded body that is leading the clinical and operational move of the three children's hospitals (Temple Street, Crumlin and Tallaght) to the new National Children's Hospital on the St James's Hospital campus, which is due to open next year.
This second review is very near completion. This is a CHI-commissioned independent review into hip surgeries for children at the children's hospital sites, as well as the National Orthopaedic Hospital Cappagh.
It is looking at a random, anonymised sample of developmental dysplasia of the hip (DDH) surgeries, between 2021 and 2023.
DDH is a condition where the "ball and socket" joint of the hip does not properly form in babies and young children. These babies are usually treated with a fabric splint called a Pavlik harness and surgery may be needed to correct the issue.
Concerns raised
CHI has said this review was set up after concern was reported that the threshold criteria being used for surgical intervention with these surgeries, may have been different across the hospital sites.
CHI said that it will ensure parents and their families are kept informed through the review process but it would not comment any further as to do so, it said, would undermine the integrity of the audit process.
Issues raised in the Dáil
In the Dáil this week, Pearse Doherty of Sinn Féin, said that last year, then health minister Stephen Donnelly was informed that hundreds of unnecessary hip operations may have taken place.
"We are talking about the possibility of young children, put under the knife, and their bones being sawed into - traumatic surgery. Children between the ages of one and seven. It's beyond the worst nightmare of any parent," Mr Doherty told deputies.
On behalf of the Government, Minister for Education Helen McEntee responded saying these surgeries are the subject of an audit. She said that she was not going to predict, nor could anyone predict, the outcome of that audit.
The minister said that parents and families of children who had operations in recent years are being written to.
She said that if the matter stretches back further, and potentially more families have to be written to, that is exactly what has to happen. We may hear more on this aspect shortly.
A key issue is that if the sample review covering 2021-2023 shows that some surgeries were not indicated, then there will be public and political pressure to look at previous years to capture the full picture.
Medical Council
The HSE has said that Surgeon A is facing a referral to the Medical Council here, which polices doctors' behaviour.
That referral relates to the serious spinal surgical incidents which are part of the Nayagam review.
Since Covid-19, Medical Council inquiries have mostly been held online, not in full public hearings, as with court cases. The status of when this inquiry into Surgeon A may proceed is currently unknown.
When such Medical Council inquiries were held in public in the past, all media, families and other interested parties could attend in person at the council's HQ in Dublin.
In these cases, a doctor who is the subject of a complaint and their legal team would also attend the physical inquiry room in person and these cases could be reported in full, for TV and radio, by the media.
The current online format, where people must register in advance, poses significant challenges in terms of coverage.
In the Dáil this week, Labour TD Marie Sherlock said Taoiseach Micheál Martin appeared to rule out a public inquiry into the practices at CHI. She said that parent groups and patient advocates have been calling for transparency and accountability.
She said that with Medical Council inquiries, the doctor does not currently have to appear in person.
"The families cannot go face to face with the doctor and there is limited access for the media. This is not in the public interest," she told the Dáil.
Ms Sherlock said the online version of Medical Council inquiries needed to change. The Taoiseach responded that he will come back to Deputy Sherlock on the matter.
Hospital consultants' body responds
Surgeon A is a member of the representative body, the Irish Hospital Consultants Association. The IHCA has said it recognises the deep distress and hurt caused to the three children and their families in the cases where unapproved spinal springs were used at Temple Street Hospital.
It said that the HIQA report highlights serious system-wide governance failures at Children's Health Ireland, where consultants were working under intense pressure with high patient care needs and workloads with inadequate support.
The association said it is within this environment that a surgeon, who is one of its members, acting with good intent and in the absence of effective structures, endeavoured to provide innovative care to children.
The IHCA added that at the time the surgeon believed the devices to be medical-grade stainless steel, CE marked as suitable for use as surgical implants.
But it said that due to the numerous failings in the hospital's procurement processes and safety checks, the surgery happened.
Luke
Children who had the unapproved spinal springs implanted have needed further surgery to remove the device.
Some parents, as in the case of Liz McMahon and David Ryan, went to the High Court in 2023 to get their son Luke's medical records released by CHI.
Luke was born with spinal muscular atrophy type 1 and scoliosis.
In July 2020, a spring was inserted into his back by Surgeon A, when he was six years old.
The family said this week it was a breach of trust and resulted in harm to an innocent child.
They called for the CHI Board to be relieved of its responsibility for the provision of services at CHI hospitals.
Following the publication of the HIQA report, Dr Jim Browne, the chairperson of the CHI Board announced his resignation and apologised for the failings in care.
The Taoiseach has said that removing the CHI Board would weaken governance further and lead to even further disruption.
Co-Founder of Scoliosis Advocacy Network Claire Cahill said they had no faith in the CHI Board or Executive.
Her 15-year-old son, Darragh, was diagnosed with early onset scoliosis at around the age of 18 months and had several spinal surgeries, but is not one of the three children in the HIQA report.
Ms Cahill said that as a parent, her concerns and fears have been increased after reading the HIQA report.
Amanda Coughlan, of the Spina Bifida Hydrocephalus Ireland paediatric advocacy group, said there was disappointment in the narrow focus of the HIQA review. She said it was limited to one specific event, one specific cohort which was a concern.
Stephen McMahon, Irish Patients' Association, said the HIQA report was the latest in a long line of tragedies that reveal the system's inability to protect the most vulnerable. He said the "fragile domain of trust has been broken".
On Monday, before the publication of the report, Minister for Health Jennifer Carroll MacNeill met the Chairperson of the CHI Board and the CHI Chief Executive, Lucy Nugent. She expressed deep disquiet at what had happened and said reform and change is essential.
We have two independent reports due to be completed and published soon. There is also the issue of a Medical Council inquiry into Surgeon A.
Waiting lists latest
This is all against the backdrop of long waiting lists for spinal surgery for children.
In one of his last acts as minister for health, Stephen Donnelly issued a legal direction to the HSE Board, that all children on the active spinal surgery waiting list at the end of December last, waiting more than four months at that time, be offered the same care package in New York or London, if appropriate.
Yesterday, CHI issued an update on waiting lists, showing that at the end of last month, there were 228 patients on the spinal surgery waiting list. This excludes 26 children who are confirmed to have their surgery in another hospital under a CHI initiative. It represents some reduction in lists but still a lot of work to do.
Some parents have expressed frustration that their children are not on the waiting list.
Mr David Moore, Head of the Spinal Surgery Management Unit, said CHI aims to have a new consultant spinal surgeon in post in the summer, to help cut waiting lists and the length of time children are waiting.
Meanwhile, there is now less than a year before the new National Children’s Hospital opens, and the three children's hospitals move over under CHI.
Parents of children who had treatment, those awaiting treatment and the wider public, will want all of their questions answered, to ensure full confidence in the future provision of children's surgery.
