A stark wake-up call for patient safety in paediatric surgery and beyond

The recent HIQA report into Children’s Health Ireland (CHI) reveals a deeply troubling lapse in oversight and patient safety. It has already led to the resignation of CHI board Chairperson Dr Jim Browne and an apology by the Minister for Health to the three young children affected and their families.

“What happened was wrong, should not have happened, and should not have been allowed to happen,” according to Minister Jennifer Carroll MacNeill.

“As patients and parents, we put our trust in healthcare professionals. That is particularly the case here where parents had put their trust in clinicians to treat their very sick children.”

The Authority had been requested by the previous Minister for Health, Stephen Donnelly, to conduct the investigation into experimental spinal procedures carried out at CHI at Temple Street. HIQA found these procedures to be a deviation from standard medical practice, which placed vulnerable children at serious risk.

What emerges is a portrait of systemic failure. HIQA’s findings point to a breakdown in clinical governance, accountability, and basic ethical procedures. No ethical approval was sought for the experimental surgical technique, nor was consent adequately obtained from the families involved. This was a violation of the HSE’s own National Consent Policy. The springs used in the procedures were not CE marked, nor intended for surgical implantation. The CE (Conformité Européen) mark is required for many products sold within the European Economic Area, including medical devices, to ensure they are safe and fit for their intended purpose.

HIQA identified that CHI’s governance structures were overly complex and fragmented, obscuring lines of responsibility and failing to ensure proper oversight. Since CHI’s establishment as a legal entity in 2019, internal restructuring led to unclear reporting lines, which in turn meant that safety checks and approval processes were either missed or ignored.

The report confirms that the families of the children who underwent these procedures were not properly informed about the experimental nature of the surgeries. This failure to communicate openly and transparently not only breaches trust, but also strips families of their right to make informed decisions about their children’s care.

In total, HIQA has made 19 recommendations: Nine directed at CHI; nine for national implementation across HSE-funded services; and one for all healthcare services, including private hospitals. These recommendations must not be treated as a checklist for bureaucratic compliance. They represent a mandate for cultural and structural change in how innovation in healthcare is introduced and monitored. Both CHI and the HSE have accepted the recommendations in their entirety and say work has already commenced on their implementation.

It is vital the lessons from this review extend beyond CHI Temple Street. The Department of Health, the HSE, and hospitals must not only reflect deeply on the conditions that allowed this to happen, but take concrete action to prevent similar occurrences in the future.