Temple Street scandal: Health Minister confirms clinicians raised concerns a year ago about spinal surgeries

Stephen Donnelly also said: “It is clear that other people knew that non-medical devices were being used” in operations on children.

“It is very important that first and foremost people immediately raise a flag. We must have a culture whereby if someone sees something they raise a flag – that would appear not to have happened at CHI [Temple Street],” Minister Donnelly said, referring to Children’s Health Ireland.

Professionals should have felt safe and secure in making such a report, which did not happen in this case – and the review would look at why not, Mr Donnelly said.

Meanwhile, the comprehensive report into the child spinal crisis will not be delivered before the end of the year, Minister Donnelly said.

No additional incidents have been notified to the Chief Clinical Officer of the HSE, Mr Donnelly said, suggesting the issue was confined to Temple Street.

Mr Donnelly, speaking in New York, said the most complex surgery was stopped within days when it first came to light, and then all surgery by the individual concerned.

He said reports that springs used as implants may have been bought on Amazon, according to one website, were tangential to the main probe. He did not confirm or deny that it had happened.

However it is understood that the actions of the professional surgeon involved did not stem from any financial motive.

Mr Donnelly said he hadn’t “got the exact date” when he was first alerted to the crisis.

“The full reports we only got earlier this week. There was a lot of back and forth over a period of time. The initial position on CHI was that they believed they could not publish the two reports. That was not acceptable to me or the chief executive of the HSE.

“When concerns were raised last year, specifically around this very complex surgery, the surgeon involved was no longer doing those and my understanding is that Temple Street stopped doing those surgeries entirely.

“So CHI moved in a matter of days. And then there was an escalating process after that. in terms of not doing other spinal surgery, not to another complex work and then not doing any clinical work.” Mr Donnelly said: “we were aware that an issue had been raised last year,” apparently referring to the Department of Health. He has said he himself learned the details in August.

Mr Donnelly said he would be meeting the independent expert who would carry out the overall probe in a week’s time. “He has full authority to go as wide as he wants and as deep as he wants.

“I’m aware that Bernard Gloster referenced that the full review may take up to a year. However, in the first instance, I am focussed on some very simple things.

“Number one is that the patients and the families involved, get full answers to all of their questions. That is absolutely paramount to what we are doing. Number two, any additional technical safety concerns around these procedures be identified immediately. I will be receiving interim reports.

“It is our intention that we would have an interim report on these highest priority issues in the coming months and the report by the end of the year. It is my intention that everything will be published.

“No additional incidents have been notified other than the ones we’re already talking about, I think that’s very important. Because parents who have children in spinal services in CHI more broadly are asking exactly this question.

“But I’m very concerned about this. I introduced a Patient Safety Act recently to make sure that we have mandatory open disclosure in our country. And it is clear that other people knew that non-medical devices were being used.

“It is absolutely essential that when people know about this, that first and foremost they immediately raise a flag. They must feel safe doing that they must be supported doing that. And indeed the Patient Safety Act mandates mandatory disclosure to patients.

“We must have a culture whereby if somebody sees something that they think is not right, or they have a concern about that, they instantly raise a flag and that would appear not to have happened. I am deeply concerned about that. And that is one of the issues that will be looked at by the external reviewer.”

Asked why it was a year before people directly impacted by this were made aware of it, Mr Donnelly emphasised that some action was taken within days of the concerns being raised.

“And then an open disclosure process was engaged with those families and we will get you an exact timeline on that. “I’ve offered to meet them at their convenience obviously, so if any of them want to meet up next week, we will of course do that.”