HSE commissions external review into aspects of orthopaedic surgery at Children’s Health Ireland at Temple Street

The HSE has commissioned a UK expert to lead an external review of elements of the Paediatric Orthopaedic Surgical service at Children’s Health Ireland (CHI) at Temple Street following a number of serious spinal surgical incidents there. The review will be conducted by Mr Selvadurai Nayagam, Consultant in Orthopaedics and Trauma, and Head of the Limb Reconstruction Unit at the Royal Liverpool University and Royal Liverpool Children’s Hospitals.

The primary focus of this external review will be the clinical care provided by an individual Consultant based at CHI at Temple Street, who is currently not conducting surgeries, and in respect of whom a referral has been made to the Irish Medical Council. This review arises from very serious concerns identified by CHI since last year relating to poor surgical outcomes in spinal surgery at Temple Street, the use of a certain spinal surgical technique and the use of unauthorised implantable devices.

In late 2022, senior management in CHI were made aware of patient safety concerns in relation to the treatment of a small number of patients with Spina Bifida who had spinal surgery at CHI at Temple Street. These concerns related to poor clinical outcomes of some complex spinal surgery, including a high incidence of post-operative complications and infections, and two particularly serious surgical incidents, which occurred in July and September 2022.

Following this, CHI commissioned two reviews: one which was undertaken internally and one which was undertaken by a team external to CHI. These reviews examined the care provided by one consultant to 17 children who had complex spinal surgery in CHI at Temple Street. Of these 17 children, one child sadly died since, and a number of other children suffered significant post-operative complications. These patients and their families already face enormous challenges due to their condition, and CHI deeply regrets the failings in the care  provided to them. CHI is  engaged with these families on an ongoing basis and will continue to provide support needed.

Separately, CHI became aware more recently that unauthorised devices were used in a small number of spinal surgery procedures. In addition to the 17 patients in the reviews, CHI has recently met two further families who were affected by this issue, bringing to 19 the total number of families who CHI have met in recent weeks. CHI has commissioned a team external to CHI to investigate this very serious matter.  The report of this investigation and all other reviews to date will be provided to Mr. Selvadurai Nayagam to inform his work.

CHI has recently met with each of these families to explain the review process to them and, if appropriate to outline to them any issues that were identified relating to the care their child received. Each of these patients have now been assigned to a new clinical team in CHI and if they have not already met their new consultant, will be meeting the consultants who will be taking over their care later this week to review and plan their future treatment. 

CHI acknowledges the anxiety that this news may cause to our patients and their families. However, we would like to reassure our patients and their families that everybody known to have been affected has been contacted.

Due to the complexity of all of the issues, the HSE has now commissioned an external review to be led by Mr Nayagam.

According to the Chief Clinical Officer of the HSE Dr Colm Henry:

“This review will examine the reports already completed and complete a risk assessment of the relevant areas of orthopaedic surgery in CHI at Temple Street as soon as practicable and before the end of 2023. This will determine the specific timelines and milestones for the review process. The review may also make findings and recommendations that apply across all CHI hospitals and to the new children’s hospital and will be published”

According to Dr Allan Goldman, Chief Medical Officer of CHI:

“We deeply regret the impact that the issues identified have had on patients and their families. We welcome the HSE’s external review. We will use the findings, in conjunction with the findings and actions from CHI’s reviews of the Spinal Surgery service at CHI at Temple Street, to inform our ongoing improvement programme.

CHI staff are committed and motivated to provide safe, effective, patient-centred and efficient care to spina bifida patients to improve clinical outcomes. We care deeply about the quality of that care. The families involved and the safety of patients remain our priority. We are in the process of putting in place measures to ensure the treatment of our patients is not disrupted or delayed as a result of this review.”

Terms of reference (PDF, 666 KB, 5 pages)

CHI Report