HSE investigates ‘catastrophic failure of incidence management’ at Crumlin

The Health Service Executive has launched an investigation into how 18 children were wrongly identified as being at the centre of a contamination scare over a medical scope at Our Lady’s Children’s Hospital in Crumlin, Dublin.

HSE director general Tony O'Brien said the events at the hospital represented a "catastrophic failure of the incident management process".

The hospital apologised yesterday after it emerged that the 18 patients whose families were originally contacted about the contaminated medical scope had not been affected. The hospital said it had subsequently contacted seven other patients.

Dr Colm Costigan, clinical director of the three Dublin paediatric hospitals, said the mix-up involved two colonoscopes – medical instruments used in bowel examinations – that failed hospital tests on July 6th.

One of the scopes was contaminated with ESBL. ESBL, or extended spectrum beta lactamases, are bugs that live in the bowel. They break down the commoner antibiotics and can make infections more difficult to treat.

The contamination was incorrectly attributed to the second scope, leading the hospital to believe 18 children treated with it may have become infected.

Minister for Health James Reilly said there had been a major communications issue at Crumlin and many people had been caused upset unnecessarily. He was very sorry about that. He "absolutely" wanted to know how it had taken place.

“I think we have to learn from this and make sure these sort of avoidable errors never happen again.”

The Minister said patient safety had to be the primary concern. “To err is human but we have to build a system that, where human error occurs, the system protects the patient from it.”

Addressing the Oireachtas Committee on Health and Children yesterday, Mr O'Brien said: "No amount of spinning by public relations consultants can mask the seriousness of the issue."

He said he had established an immediate review into how the situation had occurred.

Dr Costigan, meanwhile, said he had contacted the initial 18 families on Wednesday to explain the situation to them and had subsequently been in touch with the families of the seven other patients to inform them of the situation. The hospital intended to test the seven children to see if they carried the bacteria, he said.