Irish Patients Association analysis of HSE independent review of Tallaght. Thursday 26th March 2010

Having reviewed the agreed terms of reference by the HSE’S Independent Review group under the Chairmanship of Dr Maurice Hayes we note.

The Irish Patients Association as a cross disease Patient Advocacy body on a daily basis deals with patients and or their family’s or partners’ who have been affected by adverse events in such domains of risk to them ; as clinical, medication, management and inequity access issues.

We note with some dismay that the term “Patient” was not referred to once in the Aims and Objectives of this review. We take exception to an implied reference to patients.

We recall our key advocacy message that “Patients are the key people in our health care system and are central to all decisions every where in the health care system.” We believe that this value should assist the review in its analysis of governance and other matters.

We further question the integrity of the proposed communication process in the event of the reviews uncovering “Immediate Patient or staff Safety” while all the CEOs will be in the comms loop; Minister Harney is not included in this communication loop? Who’s going to tell her?

In addition on the 12th February 2009 Minister Harney announced that “the Office of the Chief Medical Officer has now been assigned executive responsibility for all matters relating to Patient Safety.” Who’s going to tell Dr Tony Holohan?

The following should strengthen the process from the patient’s perspective.

Our edit recommendations to the Terms of Reference in Red

Source document HSE Media Release 23rd March 2010.

HSE Media Release

Tuesday, 23rd March 2010

Tallaght Hospital Review Terms of Reference

Dr Maurice Hayes, Chairman of the Review into the delay in reporting radiological examinations and the management of GP referral letters at the Adelaide and Meath Hospital, incorporating the National Children’s Hospital, (AMNCH) today, 23rd March 2010 published the Review’s Terms of Reference.

Tallaght Hospital Review – Terms of Reference

Review of Radiology Reporting on Patents X-rays and the management of GP patient referral letters at Adelaide and Meath Hospital, incorporating the National Children’s Hospital, (AMNCH) [Tallaght Hospital]



1. Introduction

On 9th March 2010 the CEO of the HSE instructed that a review be undertaken into the circumstances that led to, and the subsequent management by AMNCH of, delays in reporting radiological examinations at the Hospital during the years 2005 to 2009.

The CEO specified that the Review would be chaired by a person independent of AMH and the HSE.

Mr Lyndon MacCann, Chairman of AMNCH and Professor Kevin Conlon, CEO Designate? of AMNCH, are supportive of the review.

Following additional information coming to light it was decided (refer to date) to extend to parameters of the review to include the management of GP referral letters at AMNCH.

2. Aims and objectives

The aims and objectives of the review

0.1 Identify the written quality procedures to handle the reporting on patient x-rays

0.2 Identify any external validation of these procedure’s eg Quality Audits

1. Identify, describe and analyse the circumstances and identify the factors, clinical, managerial and systematic, that led to the accumulation of a backlog of 57,921 unreported patient x-ray examinations at AMNCH.

2. Identify, describe and analyse the Hospital’s management of the backlog when it was identified. This will include Time Lines for identification, description and analysis of the governance and management systems and processes employed including information gathering, presentation and internal and external communication and stakeholder (stakeholder needs clarity ) engagement and importantly informing the patients involved.

3. Similarly as in 0.1 to 2 above identify, describe and analyse the Hospital’s management and processing of GP pat ientreferral letters over the time lines

3.1 Establish the scope of the any adverse events that may have happened to Patients due to the delay or non- processing of GP referral letters.

3.2 Identify risk management responses by time line by other health sector agencies .

3.3 List all designated responsible persons whose job descriptions reflect this responsibility.

3.3 report the quantity and schedule by HSE and other voluntary Hospitals of where of patient X-Rays were not reviewed by consultant radiologists and GP patient referrals that may have been delayed prior Tallaght pubic exposé – Have patients been informed were there adverse events This feeds into 4 below


4. Make recommendations that will improve services, systems and risk management at the hospital which may will be applied to other voluntary hospitals and HSE operated hospitals and which will lead to increased patient and public confidence that robust systems are in place.

5. If, in the course of its work, the review team identifies other issues which require review or investigation, the Chair shall notify the HSE.

3. Reporting Arrangements

The Steering Group shall prepare a report setting out the findings, conclusions and recommendations for submission to the HSE’s National Director for Quality and Clinical Care, Dr Barry White within 3 months of its first meeting. An extension of this deadline may be permitted upon a recommendation from the Chair to the HSE CEO.

The National Director for Quality and Clinical Care will provide copies of the Final Report to the CEO, the Risk Committee of the HSE Board, the Board of AMNCH, the Health Information and Quality Authority, the Department of Health and Children. The HSE, in the absence of any legal impediment, will publish the Final Report simultaneously on its internet site www.hse.ie.

If there is any legal impediment then is it in order to distribute the report to so many agencies?

If there are legal impediments then sections that are free from impediment should be published and reference to the areas that there are legal impediments ideally should be mentioned.

The costs of the Review should be recorded and a notional cost for wasted progressing of referrals etc.

4. Immediate Safety Concerns

If, in the course of the review any immediate concerns for patient or staff safety are identified, these will be immediately communicated by the Chair simultaneously to the CEO of the Hospital, the CEO of the HSE, the National Director of Quality and Clinical Care and the CEO of the Health Information and Quality Authority.

5. Methods to be used

The review shall be carried out in whatever manner and with whatever methods the Steering Group believes are necessary and most appropriate to analyse the systems associated with the issues set out in the aim and objectives, having regard, in particular, to the clinical judgment of the Steering Group. These methods may include, inter alia, review of documents and data and interviews with individuals. Where clinical judgement overrules avenues of investigation these should be noted.





6. Membership

Nominated BY

CEO Hse Nominee Chair Dr. Maurice Hayes

Independent Chairs Nominee Project Director Ms. Patricia Gordon

General Practice Nominee Dr. Declan Murphy

? Patient Advocate Mr. Brian O’Mahony

Nominee ? Consultant Radiologist Dr. Risteárd O’Laoide

Senior Clinician, HSE Dr. Paul Kavanagh, Consultant in Public Health Medicine

7. Liaison

For the purposes of the smooth completion of the review, Dr Paul Kavanagh, Specialist in Public Health Medicine, National Directorate for Quality and Clinical Care, will act as the liaison between the Chair and the HSE.

8. Administration Support

Sufficient dedicated and competitent administrative support will be identified to work with the review team which will be unaffected by any possible industrial relations actions.

The Steering Group has agreed these Terms of Reference at its first meeting held today 23rd March 2010.

9. Confidentiality

Individual patient confidentiality will be respected as well as any whistle blowers whose declarations are substantiated.

10. Declaration of Relationships if any.

Statements of any business and or social relationships by any review member between agencies and or persons associated with review.

END Irish Patients’Association Recommendations