Parents whose children wrongly received uncertified springs in spinal surgeries at Temple Street Children’s Hospital have called for a public inquiry.
Chairman of CHI’s board, Dr Jim Browne, resigned on Monday after the “devastating” report on child spinal surgery was published. The Health Information and Quality Authority (HIQA) found that the use of the springs in three operations, which were of a non-medical grade, was "wrong".
The report also said there was a lack of information provided to families on the new or experimental nature of the intended surgery, and therefore the request for consent from families was not in line with the HSE's National Consent Policy.
In a joint statement, The Spina Bifida & Hydrocephalus Paediatric Advocacy Group and The Scoliosis Advocacy Network said the scope of this review was too narrow, and the families directly impacted are calling for a public inquiry.
They said: “For almost a decade, we as parents and advocates could see the dysfunction choking CHI from the inside. We poured our hearts into meetings, forums, and co-design sessions — trying to fix what was so clearly broken.
"We brought our concerns to the highest levels of the HSE and government. They fell on deaf ears. While the HIQA review is comprehensive, its scope was too narrow.
"It shines a light on one appalling failure — but behind it lies a wider culture of dysfunction, disregard for safety, and systemic neglect that spans services and sites. This review must be the beginning, not the end.”
They continued: “A full public inquiry is now essential. It is what the families at the centre of this have requested, and it must begin with meaningful input from the advocacy groups who have been raising the alarm for years. The HIQA report shows, in devastating detail, how catastrophically they have been ignored.”
The review was commissioned in September 2023, after CHI said it conducted two reviews of operations on 17 children with spina bifida. It found a significant number suffered complications after surgery, with 13 children needing further unplanned surgery and one child dying.
CHI said it then subsequently learned that a consultant had implanted unapproved springs not intended for surgical use in three children. The orthopedic surgeon at the centre of this controversy ceased carrying out spinal surgery in November 2023. He has been referred to the Medical Council by CHI.
In the recently published report, HIQA found that the orthopaedic service in CHI at Temple Street had been affected by "long-standing issues with communications and team dynamics" since 2019. It believes this was a "significant factor" in the introduction of the springs because it meant important and relevant questions were not raised at various steps in the absence of a formal process also not being followed.
As a consequence, a number of key approval processes, policies or safety checks were not properly applied in treating the children, resulting in the springs being used inappropriately. As a result of the failings, the report said children were not protected from the risk of harm.
CHI board chairman Dr Jim Browne said he wanted to convey his "sincere apologies" to those who had been failed. In a statement he said: "Following discussions over recent weeks with the Department for Health, I now wish to step down and provide for an orderly transition to a new chair to allow for renewed enthusiasm and passion to guide this great organisation.
"I wish to convey my sincere apologies to the children, young people and families that have been failed by the care they received, following the release of the HIQA report today. The HIQA review found that the use of the non-CE marked springs as surgical implants was wrong and not authorised by management.
"The HIQA also review found that, while corporate and clinical governance arrangements were in place in Children's Health Ireland, there were unclear lines of reporting and accountability to ensure the safe introduction and use of new surgical implants and implantable medical devices."
Dr Browne said he will work with the Department of Health, Children's Health Ireland's executive team and board to ensure "a smooth transition to a new chairperson over the coming weeks". Sinn Fein health spokesman David Cullinane said HIQA's "devastating" report details governance, clinical, management and ethical failures.
"It says children were not prevented from harm and not protected from harm. That's a really devastating critique to have in a report by HIQA of any hospital." People Before Profit TD Paul Murphy said the operations represent "another horrific damning failure" of children with scoliosis by the State.
He said: "This was and involves a very, very serious governance, failure at CHI." Health Minister Jennifer Carroll-MacNeill echoed Mr Cullinane's assessment that the findings are "devastating". She said: "I was shocked by every element of this report."
The minister said the families involved have had another difficult day following the publication of the report. She said: "To have gone through what they did with their children and with having non-surgical springs implanted into their little bodies, and the implication of all of that is just devastating."
Speaking to RTE's News At One radio programme, Ms Carroll-MacNeill said the actions of the surgeon, however well-intended, were wrong because a series of processes were not followed. She said: "That's a problem for him but it's a much, much bigger problem for CHI (Children's Health Ireland), and for the governance of the hospital and for the governance of CHI more broadly, and that is an issue of culture, but it's also an issue of process."
She said the recommendations of the HIQA report will be implemented in full. Pressed on whether there should be other resignations, Ms Carroll-MacNeill told RTE: "What I need to do is reflect on the board and reflect on the next chairperson and the steps that are taken towards that.
"But that is something that I will do but I am looking at the governance more broadly as we move to the new hospital, and how that works." Ms Carroll-MacNeill said she wants to ensure there is appropriate governance in place.
"What I want to make sure is that every consultant who's employed in the Irish state in children's health, and in everywhere else, knows that they are not a single fiefdom, that they work within a hospital system, that they are public servants paid by the taxpayer and that they follow the rules set by us in an appropriate governance structure."
She also said a new chief executive of CHI, Lucy Nugent, had been appointed earlier this year. Ms Nugent has apologised to the affected families on behalf of CHI.
She said: "We are deeply sorry that these children, young people and families did not get the care they deserved. This is unacceptable. Children's Health Ireland sincerely regrets and apologises for the risks that were posed to three patients through the use of non-CE-marked spring implants in their spinal surgeries.
"We do not under-estimate the impact that this has had and is having on the families affected, and the distress that it has caused to all patients and families in the spinal service."
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