One of the children who underwent spinal surgery at Temple Street children’s hospital required 33 subsequents visits to the operating theatre, according to a new report.
The detail is contained in a review by experts from Boston Children’s Hospital into spinal surgeries at Temple Street, which has been published by Children’s Health Ireland (CHI).
CHI has also published the internal review it carried out into the service, where one consultant has been referred to the Medical Council.
Both the Boston review and the internal CHI review were consolidated into a report on Temple Street published by the HSE on Monday, which revealed high complication rates following spinal surgeries performed by the consultant.
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Health officials were initially resistant to publishing the original Boston and internal reviews on which the consolidated report was based, but have now done so in response to calls from patient groups angered at this week’s revelations.
CHI said that while all of the reports’ findings were published on Monday, it was now publishing the two reviews in full “in response to requests from families and a wish to be as open and transparent as possible”.
Both reviews focus on patient safety concerns around spinal surgeries conducted at Temple Street between October 1st, 2019 and October 31st, 2022. Reviewers, who did not assess physical conditions at the hospital, such as space and equipment, looked at the files of 16 children with spina bifida who underwent spinal surgery during this period.
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Given the high incidence of spina bifida in Ireland, and the increased risk of scoliosis with spina bifida, “careful consideration must be taken when assessing the high demand for spinal surgery”, the Boston review states.
“CHI at Temple Street’s waiting time for surgery did not appear to have a negative impact on the increased rate of post-operative complications. However, high-complexity surgery requires significant resources and therefore if these surgeries are going to continue to be done at CHI at Temple Street these resources need to be available. Alternatively, CHI leadership may want to consider and assess the opportunity to offer some or all these surgeries at another CHI facility.”
Citing “concerns” raised about outcomes from spinal surgery, the team recommends that Temple Street “should continue to provide oversight and increased training for staff for medically complex patients undergoing spinal surgery”.
“A unified programme structure/governance around care for children with spina bifida is important. Leadership, engagement, and accountability between surgeons and other clinicians are cultural mainstays. Solid governance structure with clinical leadership, enhanced interdisciplinary forums, and a quality improvement programme will support care planning and allow for benchmarking of programme performance.”
More attention is needed in Temple Street to create a culture where all members of the care team are encouraged and comfortable sharing safety questions and concerns,” according to the review.
“To truly create a highly reliable safety culture, CHI at Temple Street should look at other high-reliability paediatric institutions that have successfully developed environments focused on patient safety and quality. Leadership should carefully be proactive in addressing any and all concerns whether raised by clinical or other staff, families, regulators or others.”
Repeat surgery
Transparent clinician accountability and standards, role clarity across clinicians, and a defined governance structure are critical to the future success of the programme, the review adds.
The Boston review provides a detailed breakdown of the 16 case files reviewed. Of the cases analysed, the children ranged in age from five to 17 years, with an average age of seven. Eleven were girls and five were boys.
As reported earlier in the week, it found more than 80 per cent of cases required repeat surgery, 75 per cent suffered wound infection and 56 per cent needed to have metal implants removed.
The average number of visits to the operating theatre was 6.5, with a highest number of 34.
Three children experienced hypothermia, defined as under 35 degrees, during a procedure, according to the internal CHI review. The average time spent by a patient under 35 degrees was 180 minutes, skewed by one child who spent 360 minutes in a hypothermic state.
As not all information was available, all medical specialties should be encouraged to improve documentation, the review recommends.
Minister for Health Stephen Donnelly said his department was informed in August that there were issues in relation to unauthorised medical devices being used as part of spinal surgeries in Temple Street Hospital. He described the controversy surrounding the treatment of 19 children at Temple Street, including one 10-year-old girl who died, as “absolutely heartbreaking and devastating”.
“As any parent, as the father of three children myself, it is unspeakable. It should never have happened,” he said.
