HIQA’s report into failures of patient care and corporate governance at Tallaght Hospital is now with the Comptroller and Auditor General and the fallout may rumble on for some time. June Shannon reports.
HIQA’S comprehensive 294-page report on its investigation into the quality, safety and governance of care provided by Tallaght Hospital have far reaching implications for the hospital, the HSE, the Department of Health and the State. The serious concerns in relation to financial accountability ra-ised has lead HIQA to refer the report to the Comptroller and Auditor General (C&AG).
Amongst these concerns is that the hospital awarded a contract worth €1.8 million to a consultancy firm without entering into a tendering exercise, receiving formal approval from the hospital board or even agreeing costs at the outset. Red flags were also raised in relation to the fact that significant supplementary payments were made to staff for taking on additional roles. However the governance behind these decisions was unclear. In one case an individual was paid in excess of €150,000, the report found.
Furthermore, the investigation, which focused on a particular time period from 2010 to 2011 and included the later part of the term of the old hospital board, revealed that there was no remuneration committee in place at the hospital. It also found that board meeting minutes did “not record where the remuneration for the Chief Executive and members of the management team were discussed”.
The report noted that the controversial €1.8 million contract was awarded at a stage when the hospital was facing an end of year deficit of €5.8 million.
Speaking at the launch of the report, Dr Tracy Cooper, CEO of HIQA described this as “a total failure in financial controls” and said the Authority had serious concerns in relation to how taxpayers’ money was being managed by the hospital.
In a letter to the Office of the C&AG in February, HIQA raised six areas of “potentially serious concern”. These included possible non-compliance with the Code of Practice for the Governance of State Bodies, possible failure to comply with public procurement legislation, and HSE budgetary and performance oversight pursuant to Section 38 of the Health Act 2004.
Speaking to the Medical Independent (MI), a spokesperson for the C&AG said the office will examine the matters raised by HIQA and if there is an issue that merits public reporting, it will act on that.
“If any issues arise, they will be pursued in the first instance with the HSE,” the spokesperson said.
Minister for Health Dr James Reilly has also revealed that the Chief Medical Officer of the Department of Health Dr Tony Holohan has referred the report to the Medical Council and An Bord Altranais.
In a statement to MI, the Council said: “The Medical Council has been contacted by the Chief Medical Officer. The report will be referred to the Medical Council at an upcoming meeting and it will consider its contents. The Council would not be in a position to make any further comment until it has considered this issue.”
Patient care
While serious concerns in relation to financial accountability and governance were central to the faults found at Tallaght, the role of acute hospitals in ensuring patient safety was at the heart of HIQA’s report.
The Health Minister said: “We must never forget that this report is first and foremost about patient safety and that it all began because of the death of a patient on a trolley in a corridor adjacent to the emergency department.”
The investigation looked at the quality, safety and governance of patient care at Tallaght Hospital, in particular for patients admitted through the ED.
It stemmed from the tragic and unexpected death of a 65-year-old man in March last year who was admitted with ankle pain. Mr Thomas Walsh passed away on a trolley in a corridor, which the HIQA report describes as “a main thoroughfare”.
According to the report, “ill patients lay waiting on patient trolleys or sat on armchairs, with an insufficient level of privacy or dignity. The physical congestion and absence of basic facilities associated with the use of the corridor as a waiting area for ill patients compromised the quality and safety of care for these people and also compromised the assessment of newly arriving patients in the ED.”
“The use of the corridor at the hospital was wholly unacceptable to the Authority,” the report adds.
The investigation found that, at the time, patients attending the ED who required admission were accommodated either within the ED or on the corridor near the department.
According to the report, “over 80 per cent of the admitted patients were accommodated on the corridor adjacent to the ED and waited, on average, a further 13 hours for an in-patient bed.” It found that the longest waiting time reported was 140 hours.
“This was an unacceptable situation for patients,” the report states.
“The cultural belief by individuals in any hospital that the routine practice of accommodating patients on trolleys in corridors is acceptable should not be tolerated. This is not acceptable for patients and the public and should cease,” it says.
The situation at Tallaght was allowed to continue for some time and despite repeated attempts by HIQA to receive assurance from the hospital, it ultimately took the unexpected death of a patient before any real action was taken.
Serious concerns were raised about the ED at Tallaght Hospital as far back as 2009, three years before the death occurred.
Addressing the Oireachtas Health Committee in the Dáil last week, Dr Cooper said: “HIQA’s concern was, at what point did the HSE say, ‘Stop, we need to do something more about it’.” Many staff at the hospital raised concerns, but these issues were not acted upon,” she said.
According to a HIQA report in September 2009, “the Authority received information relating to the health and safety of patients in the ED, in particular the use of the corridor adjacent to the ED to accommodate patients who were admitted and awaiting transfer to an in-patient bed”.
As a result of these serious concerns, HIQA “repeatedly sought assurances” from the hospital that these risks in relation to patient safety were being managed and were advised by the hospital that “reports would be forthcoming”.
No improvement
The hospital advised HIQA that “a health and safety assessment had been carried out by the Health and Safety Authority (HSA) in April 2010, with an improvement notice issued, and that the hospital’s ED taskforce was completing a process of improvement projects to improve the patient journey through the ED”.
The report found that “in July 2010, the Authority received written confirmation from the hospital that all immediate risks to patient safety across the organisation had been addressed”.
However, just five months later, HIQA received information from doctors working in the ED at Tallaght that the situation there “had not improved, with overcrowding in the ED impacting on the timeliness of patient triage and assessment”. The Authority was also told that as many as “50 patients were being regularly accommodated on the corridor adjacent to the ED awaiting transfer to an in-patient bed”.
In April 2011 the Acting CEO advised HIQA of “the unexpected death of a patient who was receiving care on the corridor area adjacent to the ED of the hospital while awaiting admission to an in-patient ward”.
Speaking at the launch of the report earlier this month, Ms Hilary Coates of HIQA, who lead the investigation, said the board of the hospital “did not have patient safety firmly on the agenda”.
She said that a there was a lack of good faith reporting processes which meant that concerns raised by emergency clinicians and other staff did not receive a timely response.
According to HIQA CEO, Dr Tracy Cooper, individuals at different levels of authority and responsibility shared their concerns with HIQA during the investigation.
However, she asserted that “the hospital didn’t seem to be able to actually organise itself in order to do something about it”.
“At the heart of this is a hospital being able to act when something like this [is] happening and it didn’t,” Dr Cooper said.