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Hubris at the heart of latest Tallaght scandal
[ by Niall Hunter, Editor www.irishhealth.com]
Here's a horror story from the medical archives:
A 65-year-old male patient has to endure being treated in a corridor adjacent to an overcrowded A&E in a Dublin hospital. Having attended the hospital with severe ankle pain, and having been forced to sit on a chair throughout his stay, he eventually dies in undignified, unsanitary and unsafe conditions.
Cause of death - cardiac arrhythmia secondary to bronchopneumonia. His death is classified by the hospital as 'unexpected'.
An internal investigation reveals that the contributing factors in his death were the sub-optimal environment of the corridor for patient accommodation, the lack of an early warning system to identify a patient whose condition is deteriorating, lack of communication between hospital teams and limited care plans for A&E patients awaiting admission.
You've probably guessed it at this stage - this didn't happen in 1911, but in March 2011 in Tallaght Hospital. And it has probably happened many times in many other hospitals as well.
Just over 330 adverse incidents were reported in Tallaght's A&E and the corridor adjacent to it in 2010, half of them related to treatment. Two 'unexpected deaths,' including the case referred to above, occurred there in March and July respectively in 2011.
Everyone's sympathies will go out to the families of the two men who died in undignified and unsafe circumstances as a result of this particular hospital safety scandal.
Mr Thomas Walsh's death in March 2011, sparked the HIQA review into how Tallaght treated patients in its emergency department. Hopefully it's not too crass to propose that he did not die in vain.
Hopefully, HIQA's shocking findings will ensure that hospitals finally implement systems which have patient care and safety as their driving goal. At the very least they are likely to end forever the negligent practice of hospitals allowing patients to be treated in corridors.
And some depressing points of information are relevant here. Mr Walsh died in Tallaght's ED corridor in March 2011. At the inquest into Mr Walsh's death inquest in June, the Dublin County Coroner questioned the safety of Tallaght's ED services.
In spite of this, Tallaght continued to use its unsafe ED corridor to treat very ill patients until the end of August, when it was requested to cease doing so by HIQA.
Indeed, the second unexpected death of an emergency patient, 79-year-old Thomas Brennan, occurred at the hospital in July 2011. At the inquest into this death on August 11, the coroner again raised safety issues about Tallaght's emergency department.
And those us with not so long memories will recall that another major review report on patient safety was published about Tallaght Hospital in November 2010. The Hayes review looked into the issue of unreported x-rays and unprocessed GP referral letters, and recommended operational and governance changes in the wake of this particular scandal.
This Hayes review queried why Tallaght's managers and governors did so little to avert the x-ray and referral letter crisis.
In spite of this damning report, patient safety continued to be compromised in another part of the hospital, its ED.
HIQA says in December 2010, one month after Hayes reported and Tallaght said it was acting on its findings, emergency medicine consultants informed the safety body about ongoing concerns regarding the management of risks to patients in the ED, particularly with regard to patients being treated on a corridor.
This unsafe practice continued at the hospital for a further eight months.
History, as they say, repeats itself, first as tragedy, then as farce. Except the HIQA findings represent another tragedy, another scandal. Will anyone really be held accountable for this? Time will tell, but let's not hold our breath.
We should be grateful, however, that HIQA has yet again lifted the lid on what goes on in our health service. It has given us an insight into what happens and needs to be changed that would never see the light of day if we were solely relying on hospitals and the health authorities to account for their actions.
Hopefully too, the report will galvanise hospitals, the HSE and Health Minister James Reilly to implement a system that ensures that nobody dies unnecessarily in EDs, and nobody is treated in conditions that lack dignity of privacy.
A system that ensures that hospitals as a whole stop paying lip service to 'patient-centred care' and actually provide it.
And please, please - stop producing these ridiculous 'patient charters', which start to gather dust as soon as they're off the printing presses.
The latest one, I kid you not, gives great emphasis to the patient's own responsibilities relating to their care. Memo to HSE - wrong place, wrong time for that type of exhortation.
Instead, let HIQA's recommendations on how hospitals can provide an efficient and humane service act as the latest 'patients' charter.'
James Reilly is making efforts to improve the 'patient journey'. He would do well to use the HIQA report as a road map.
But let's move away for now from the long-documented issues in our hospital EDs, important and tragic though they are.
Because the HIQA report provides us with the key to why many things have been so bad in many of our hospitals for so long.
This key, in many cases, is lack of accountability, or if you like, institutional hubris and arrogance. Remind you of any particular sector of the economy that's got us into a bit of trouble recently?
HIQA's Tallaght report shows us how cavalier, if you want to use a polite word, some of those running the hospital were with its finances. Or should we say, our finances, as it is a public hospital spending public monies.
They failed to follow proper public procurement procedures for a €1.8 million consultancy contract - no tendering, no prior Board approval or agreement on the costs from the outset. Ironically, the consultancy advised on improving governance.
Here's some free advice on how to improve hospital governance and management - don't pay out quite so much for someone to tell you how to do it. Better still, try to work out how to do it yourselves - it surely can't be rocket science.
And if you do feel the urge to break the bank when hiring experts, go through the proper processes of public accountability, if it's not too much trouble.
There was also a clear lack of accountabillty within the hospital on the handing out of €739,000 in additional payments to senior staff - one staff member got an extra €150,000 in 'top-up' pay. HIQA said it was not clear how decisions were made and on what basis, to pay out these monies.
And of course the public was never informed about all of this - until now, when yet again we had to rely on an independent watchdog to open a can of worms on our behalf. For without HIQA, FOI and 'whistleblowers' we would never really learn anything about what's going on behind the walls of our hospitals.
It goes without saying, (but we'll say it anyway) that most of the monies referred to above were paid out quite recently, at a time when Tallaght Hospital was cash-strapped and cutting back services, and when the country was deep in the financial mire. Yes, we know, it still is.
The lesson from the Tallaght report is that many voluntary hospitals and other areas of our health service are about as publicly accountable and open as a masonic lodge.
How many other Tallaghts are out there? How many more safety and governance revelations are lurking in the undergrowth?
It's appropriate that one of the HIQA report's recommendations is that the business of hospital boards in receipt of State funds should be conducted openly and transparently, and all boards should hold the maximum amount of their meetings in public by June 2013.
The lack of accountability on how hospitals' resources are spent and how much the public is told about what they are doing with our money feeds into the provision of deficient hospital care. It's the 'no-ones's minding the shop' syndrome. A constant theme through recent scandals is how little the HSE, who should be minding the shop on our behalf, knew about them.
Poor hospital care, when it occurs (and there are of course many examples of excellent care) is a by-product of some hospitals being run with the openness and inclusivity of your average golf club. In other words, 'we know best so don't ask questions because we've been spending your money and running services any way we please for years.'
Well, the HIQA report shows that you clearly don't know best - and it's about time that your hospitals were run for the people who use them and pay for them, and not for internal power elites operating under laughably defective management and oversight systems.
And while we can be grateful (but only slightly) that Tallaght has begun to improve how it cares for patients and how it runs its affairs, we should remember that this only happened after patient safety had been compromised, and patients had actually died, due to serious managerial and governance deficiencies.
A worrying final point. Health Minister James Reilly's plans for independent hospital trusts could conceivably give some of these institutions even more independence than they already have. God help us.
The need for proper regulation, oversight and accountabilty in Dr Reilly's brave new health system has been made very clear from the findings of HIQA's Tallaght report.
Tallaght- unsafe ED caused patient death
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