Tallaght hospital: Deep roots to events hogging headlines

It was at the end of a long working day and, more relevantly, a very long week in the life of their workplace, when the consultants of Tallaght hospital trooped in for a special meeting of the medical board last Monday evening.

There was only one item up for discussion – the adverse publicity the hospital had received in the preceding days. The revelation a 91-year-old patient had spent 29 hours on a trolley had generated banner headlines, which grew larger when it emerged that the hospital had ordered an investigation into the leak.

Just three years after the publication of a damning report on the way the hospital was run, Tallaght was back in the news. Most of the consultants present were deeply unhappy, not just with the media coverage but with their colleagues in the emergency department, whose whistleblowing activities led to the leak about the trolley patient.

Why was Tallaght “taking the hit” for what was a national problem with overcrowding in emergency departments, speakers asked. What would be the effect of the negative publicity on the hospital and on individual practice? Was the hard work since 2012, when the Health Information and Quality Authority (Hiqa) report recommended major reforms, to be set at naught?

Dr James Gray, the emergency department (ED) consultant who alleges he has suffered intimidation for speaking out about overcrowding, was present for some of the criticisms of his actions but left after defending his advocacy for patients. The meeting continued and an agreed statement was hammered out.

The statement sent to the chairman of the hospital board, Michael Scanlan, expresses "grave concern about the extent of patient information recently released and discussed in the media".

It continued: “However, the medical board also considers that all consultants and staff have a duty of care, individually and collectively, to all patients of Tallaght hospital. This includes a responsibility to advocate responsibly and effectively on behalf of patients’ needs while preserving confidentiality such that no information that potentially identifies any specific patients is disclosed in any public forum.”

The hospital stayed silent last week during the height of the controversy. Only Prof Des O'Neill, a geriatrician at Tallaght (and Irish Times columnist) appeared on the airwaves, though not in a representative capacity.

He attributed the problem in the emergency department to "several billion [taken] out of the health budget" in recent years, along with rising demand and an ageing population. There wasn't a single clinician in the hospital who wasn't upset at the state of affairs and trying to change them, he told RTÉ Radio.

Non-ED doctors contacted for this article gave various reasons for not speaking publicly on the issues convulsing the hospital: an adherence to medical collegiality; fears that their comments could prejudice future inquiries or legal proceedings should these arise; and concerns the reputation of the institution will suffer more.

Another consultant who alleges intimidation over her whistleblowing activities, Dr Jean O’Sullivan, sent a lengthy memo to colleagues after the medical board meeting. She said she understood there was a “lot of discomfort” about the media attention.

“Many colleagues here have been personally critical of the EM consultants for externalising our concerns for patient safety to Hiqa and other agencies, without any insight into how local management here handled our concerns.

“What would you have done?” she asked her colleagues. “We have at no time criticised the excellent clinical care being delivered at the hospital. It is the rampant corporate governance failures locally and in the HSE that we have publicly criticised.”

But as one doctor pointed out, many consultants occupy managerial roles as clinical directors, so it is hard to separate corporate and clinical governance.

Trolleys

While the events of the past week appeared to have come out of nowhere, they have deep roots. And while trolleys loom large in the controversy, the frustration of Dr Gray and Dr O’Sullivan at the hospital’s failure to take seriously their allegations of intimidation has played a major part.

Dr O'Sullivan filed a complaint alleging intimidation and obstruction of her highlighting of patient safety issues in 2011. With the passage of time, she would grow increasingly frustrated with the lack of progress in investigating her concerns. Last September, she contacted Leo Varadkar about her concerns; the Minister has since instructed the hospital to undertake an investigation.

Dr Gray made his own complaint alleging intimidation and bullying, arising from his advocacy work, the following year. While former chief executive Eilish Hardiman sought to “draw a line under the past”, as she wrote to Dr Gray, efforts at resolving matters using mediation have so far come to nothing.

The seminal events that underpin the internal conflicts within Tallaght occurred in 2011, when two patients died after being boarded on trolleys in the hospital corridor. In both cases, the hospital objected to parts of the statements filed by individual ED consultants.

Dr O'Sullivan took the unusual step of engaging her own legal team before appearing at the inquest into the death of Thomas Brennan (79) who suffered a heart attack while on a trolley in Tallaght.

As reported at the time, acting chief executive John O’Connell told the inquest that Mr Brennan “could not have been in a better or safer place” but Dr O’Sullivan’s evidence was that “no human being should be left on a corridor when they require a bed”.

‘In dispute’

Mr O’Connell claimed Dr O’Sullivan was “in dispute” with the hospital over working hours and said she was treating patients in her office.

Under questioning by her barrister, he agreed she was not breaching her contract and the patients she had treated in her office had been referred to her by the courts system.

Unlike many specialists, emergency medicine consultants do not generally have private patients, as ED is part of the public health system. However, they may write reports for lawyers, insurance company doctors and the Garda Síochána on patients treated in hospital for their injuries. Such medico-legal work is allowed under the terms of their contract.

The coroner recorded a verdict of death by natural causes and accepted there had been no evidence that any treatment could have changed the outcome.

In the second inquest, Dr Gray was asked by the coroner to submit a statement and opinion in relation to the death of Thomas Walsh, again after spending hours on a trolley in Tallaght.

Before the inquest, lawyers for the State Claims Agency, which handles medical negligence claims against hospitals, asked him not to submit his opinion deposition, he says.

It is clear the agency was concerned about the possibility Mr Walsh’s family might sue over his death. While it had no issue with Dr Gray stating his views in oral evidence, this would not form part of the official record. Generally, no stenographer is present at inquests and the official record comprises only the depositions and the verdict recorded by the coroner.

In his opinion deposition, which the coroner allowed him to give, Dr Gray claimed the patient “should have been more closely monitored” and criticised the “appallingly poor standards of both patient and staff confidentiality, privacy, human dignity and sanitation”.

He claimed the office of the chief executive was ultimately responsible for allowing the practice of boarding patients on corridors and in alcoves.

The coroner, while returning an open verdict, appeared to take his cue from Dr Gray by commenting that Tallaght “sounds like a very dangerous place”. The inquest attracted considerable publicity and the following day, Hiqa announced a statutory investigation into the hospital, the first time it had used its powers for such an inquiry. Tallaght was only just recovering from a 2010 scandal involving unreported X-rays and unprocessed referral letters.

Its report, published the following year, found no one was responsible for the patients left lying on trolleys in the hospital and was highly critical of governance standards. “The findings of this investigation reflect a history of longstanding challenges in the leadership, governance, performance and management of the hospital which were manifest in the persistent, and generally accepted, tolerance of a wholly unacceptable practice of patients lying on trolleys in corridors for long periods of time.”

Among its 77 recommendations was a ban on trolleys in corridors, not just in Tallaght but in all hospitals.

Corner turned

It seemed as though the corner had been turned. The hospital board was slimmed down, new managers appointed and trolleys in corridors duly banned.

It also appeared the ED consultants were vindicated. New hospital chief executive Eilish Hardiman wrote to them in May 2012 saying she accepted they had rightly raised patient safety concerns from 2009. She agreed the use of corridors to house patients was unacceptable and said the hospital was anxious to get to a “no trolleys” position for both the emergency department and wards.

She added: “This will involve changes in clinical practices for ED and in-house teams and staff and I welcome your confirmation of support to work on these changes.”

However, the curse of overcrowding would soon return with a vengeance in hospitals across the country. Last June, the hospital apologised after The Irish Times revealed a 101-year-old woman spent 26 hours on a trolley in the emergency department.

With overcrowding on the rise again nationally, it was only a matter of time before there was renewed controversy over individual cases. Given Dr Gray’s penchant for firing off letters of complaints to multiple recipients, it was highly likely Tallaght would feature.

So it came to pass, when a leaked memo from Dr Gray showed that a 91-year-old with Parkinson’s languished 29 hours on a trolley in the hospital.

Twist

This time, though, there was a twist; far from being outraged at the treatment he received, the patient was unhappy at his personal details appearing in the media and at the way his case was characterised.

The case highlights an unresolved tension inherent in cases of medical whistleblowing. Journalists believe information should be disclosed where it is justified in the public interest, but doctors, while having a duty of candour, cherish patient confidentiality.

While few personal details leaked about the patient on the trolley, those that did emerge were sufficient for the man to be able to identify himself. He complained and the hospital ordered an internal review of the leak. Tallaght says it had no option but to do so once a patient had complained, but making a virtue of this through a public announcement was probably a mistake. The decision changed the public narrative; instead of being about the umpteenth “patient languishing on a trolley” story in the health service, it became a story about “gagging the whistleblower”.

To compound matters, management went to ground just as the controversy took off. The chief executive, David Slevin, cancelled a television appearance at short notice.

Just two years in the job, Mr Slevin has inherited a thorny and complex set of issues in the hospital. Patient groups speak highly of the youthful chief executive; Triona Murphy, chairwoman of the Tallaght Hospital Action Group, says he has proved more accessible than any other chief executive since the 1990s.

Flood of support

Dr Gray, an avid Twitter user, received a flood of support online and from the wider medical community but the silence of his hospital colleagues outside the ED department told its own story.

The irony is that Tallaght’s performance, while not outstanding, is better than many comparable hospitals. Just over half its emergency department patients are seen within six hours and 72 per cent within nine hours, slightly below the national average, according to the latest HSE figures. In August, 957 patients, or 3 per cent of the total, spent more than 24 hours in emergency in Tallaght. That compares with 2,600 in the Mater, 3,800 in Beaumont and 3,000 in St Vincent’s.

Among patients aged 75 years and over, just 18 per cent were admitted from ED within six hours in Tallaght. This was still better than St Vincent’s (5.5 per cent) and Beaumont (2.3 per cent).

The controversy has cast the hospital in a disproportionately bad light, Triona Murphy believes. “The emergency department seems to be at the centre of the medical universe these days, and perhaps that’s what is annoying other people in the hospital.”

“The ED crisis is chronic and awful for sure, but so are the problems with waiting lists,” she says. Tallaght has almost 20,000 patients on its outpatient waiting list. More than 1,100 of these are on the list for over 18 months in breach of Mr Varadkar’s target, and therefore attract a fine. “They’ve been put in an impossible situation.”

Dr O’Sullivan has contrasted the inaction on trolleys with efforts to ban drink-driving. “To save lives from drink-driving, we had to ban it. Would the electorate have tolerated politicians saying, ‘well, here comes December so I suppose we’ll have a surge in drink-driving’. No, they and the families of victims of drink-driving demanded better than that and succeeded.”

The intervention of Mr Varadkar spurred the hospital into action in relation to the complaint filed by Dr O’Sullivan. In a letter to the consultant last January, board chairman Michael Scanlan admitted the failure of the hospital to deal with the issues raised in her complaint was unacceptable to all those affected.

A formal investigation of Dr O’Sullivan’s complaint is due to start shortly, assuming no other obstacles arise. The issue of overcrowding, though, is getting worse, with attendances up one-fifth this year and trolley numbers rising as a consequence.

Mr Varadkar is due to attend Tallaght in the coming weeks – for the official opening of the new emergency department. It should be an interesting visit.