In April 2009, the Health Information and Quality Authority published its investigation report into Mid-Western Regional Hospital (MWRH) Ennis.

The Authority undertook the investigation following serious concerns raised by family members following the deaths of two patients who received treatment at the hospital and further concerns by families about the quality of care received across a variety of services provided.

The Authority’s investigation report concluded that “Change for safety must happen” and that it was unsafe to keep the configuration of services as they were. The Authority made a series of recommendations to the HSE aimed at improving patient safety at MWRH Ennis and nationally.

The Ennis investigation report recommended that the HSE should systematically review services in all hospitals similar in profile to MWRH Ennis with a view to identifying whether specific services were as safe as possible and make necessary changes for patient safety. The recommendations made it clear that, in hospitals where service changes are needed, appropriate clinical risk management measures should be put in place.

Following further requests from HIQA to the HSE for a formal report on progress with implementing the Ennis report recommendations, the Chief Executive of the Authority wrote to the Chief Executive of the HSE in June 2010 requesting a report on progress against the full range of recommendations and in particular those relating to hospitals similarly configured to MWRH Ennis. This coincided with correspondence from the Authority seeking assurances from HSE South that the key recommendations from the Ennis Report had been implemented in Mallow General Hospital.

In August 2010, the Board of the Authority took the decision to instigate an investigation into the provision of services at Mallow General Hospital following information received about the care of a patient with complex clinical needs who subsequently died at another hospital.

In September 2010, subsequent to the launching of the Mallow Hospital investigation, the Authority received for the first time a national HSE report setting out, by HSE region, issues raised in the Ennis report recommendations as they related to acute clinical services in similarly sized hospitals to MWRH Ennis. This HSE report was also the first evidence received by the Authority of a systematic approach to assessing and addressing the relevant issues in hospitals similar to MWRH Ennis – a central thrust of the Ennis report recommendations. The HSE report to the Authority identified these hospitals as:

• Our Lady’s Hospital, Navan
• LouthCounty Hospital
• MidlandRegional Hospital, Portlaoise
• St Columcille’s Hospital, Loughlinstown
• MWRH Ennis
• MWRH Nenagh
• St John’sHospital, Limerick
• RoscommonCounty Hospital
• Mallow GeneralHospital
• BantryGeneral Hospital.

The Authority considered this HSE report to be of serious concern in that it suggested that, 18 months after the publication of the Ennis investigation report, a number of these hospitals continued to receive 24-hour emergency attendances with insufficient measures outlined by the HSE as to how clinical risks were being identified and managed. There were apparently few systematic arrangements for mitigating the risks to patients in these services, as highlighted previously in the Ennis report, beyond protocols for ambulance bypass for major trauma patients in some cases.

Specifically the Terms of Reference for the Mallow Investigation included reviewing the extent to which the patient safety recommendations of the Ennis report, that cover these type of issues in more depth, had been implemented by the HSE in Mallow and in similarly sized hospitals nationally.

The Authority received, in February 2011, an updated version of the HSE report covering the above hospitals, describing further actions taken by the HSE. This updated report was published by the Authority in its Mallow Report in April 2011.

By early February 2011, the risk mitigation plans for each site had yet to be completed or implemented by the HSE. This was not satisfactory and there is a potential for patients who continue to receive acute services in such hospitals to continue to be at risk.

Given the above evidence, the Mallow Investigation Team concluded that no formalised systematic review of risks relating to small, stand-alone hospitals, as highlighted in the Ennis investigation report, took place until summer 2010 at the earliest, well over a year after the publication of the Ennis investigation report. It also concluded that having reviewed these risks, the HSE had not provided sufficient evidence that they were being effectively managed to reduce potential risks to acutely ill patients in a number of such hospitals.

At the time of the publication of the Mallow Report, patients continued to be referred or present themselves to small local hospitals with emergency departments on the presumption that they had the staffing and infrastructure in place to meet all their needs, when this may not have been the case.

In a health system built on the premise that local access to services is maximised, it is absolutely vital that the mechanisms for identifying, and directing to the right place, patients who need care in specialist centres are as effective as possible. Given the potential risks to such patients of finding themselves with a complex or rapidly deteriorating condition in a hospital with insufficient numbers of suitably qualified staff to deal with their needs and not enough numbers of these types of patients to maintain the skills of clinicians, this should be a major focus of those responsible for planning and providing services.

The interests of such patients should be at the heart of clinical governance, risk management and performance management in the health service.

In this context towards the end of June 2011, the HSE confirmed to the Authority that it had serious concerns regarding the range and type of services provided at Roscommon Hospital that reflected the risks to patients in small hospitals that had previously been identified in the Ennis and Mallow reports and that these risks were also being compounded by the shortage of non-consultant hospital doctors (NCHDs).

The HSE also informed the Authority that it had made the decision to change the services in Roscommon in order to address the patient safety issues. These changes are consistent with the recommendations of the Ennis and Mallow reports and the Authority supports the new model of services that is being implemented by the HSE in Roscommon.

Conclusion

The Authority’s two statutory investigation reports into Ennis and Mallow hospitals identified serious concerns for patient safety at these and similar sized hospitals. The reports contain a series of recommendations aimed at improving patient safety across the system that should be implemented in full.

The Authority has not recommended the closure of any hospital. However, it has made recommendations on how to improve the quality and safety of services for patients and identified that these smaller hospitals must have a pivotal role in providing a wide range of safe services to their communities that can safely be provided by these hospitals.  It is the responsibility and duty of Board of the HSE to oversee the implementation of the recommendations from the Ennis/Mallow reports and the Health Information and Quality Authority as its regulator will continue to hold the HSE to account in doing so.

Finally, it is the Authority’s view that change for safety is long overdue in many aspects of our health system. The Authority recognizes and understands the difficulties in bringing about these changes. However, further procrastination and delay is not acceptable and can put patients’ lives and safety at risk. The Authority will continue to highlight patient safety concerns as they arise and evaluate and monitor the HSE’s implementation of our recommendations and future compliance with national standards.

• Read the Mallow General Hospital investigation executive summary report and recommendations
• Read the Mid Western Regional Hospital Ennis investigation executive summary report and recommendations

Further Information: 

For further information please contact:
Marty Whelan, Head of Communications and Stakeholder Engagement
01 8147481/ 086 2447623 or email mwhelan@hiqa.ie