HSE Internal Audit Report recommends actions to further strengthen governance of waiting lists at CHI

The HSE has today published a Review of Governance and Equity in Patient Access and Waiting List Management at Children’s Health Ireland (CHI).

At the request of the Minister for Health, the former HSE CEO requested the HSE Chief Internal Auditor to undertake an audit to assess governance and equity in patient access and waiting list management at CHI following concerns raised in previous reviews. The aim of the audit was to review governance, access to care, payment practices, waiting list and NTPF oversight and assess the balance between public and private patient management in the period January 2023 to May 2025.

The audit reviewed three specialities – Orthopaedics (including Spinal), Urology and Respiratory Medicine and looked at processes for patient referral pathways, waiting list administration and whether Waiting List Action Plan or NTPF initiatives met the required conditions for funding.

The report found no clear evidence of inequity in access to care. While the review was constrained by data and system limitations, it identified consistent systemic issues affecting waiting list governance, transparency and assurance.

Across the 3 specialties

• Patients experienced delays beyond recommended timeframes, driven primarily by capacity and workforce pressures.
• Documentation and data quality were frequently incomplete or inconsistent, undermining the ability to evidence compliance, clinical prioritisation, and accurate waiting list management.
• Governance arrangements for HSE/NTPF-funded initiatives and core activity measurement were underdeveloped, limiting assurance on value for money and additionality.
• Broader weaknesses in data management, policy controls, and oversight structures further reduced transparency and accountability. Elements of the future consultant private practice model at the new children’s hospital remain to be finalised.

The audit also recognised evidence of

• increased activity,
• reductions in some long-waiting cohorts,
• improvements in average waiting times,
• expansion of nurse-led models of care, and
• use of NTPF and HSE-funded initiatives to provide additional capacity beyond routine service delivery.

In response to the Internal Audit Report CHI has developed an action plan with 32 actions to address the recommendations from the report, 20 are either fully or partially complete with 11 still in process, 1 further action will commence once actions are implemented.

In addition to the Internal Audit a separate narrative review was commissioned by the HSE CEO to add a qualitative dimension which involved capturing patients, their families and staff experiences of Waiting List Management at Children’s Health Ireland to inform future improvements.

This narrative review provides important patient and family feedback and reveals dissatisfaction with waiting list management, characterised by long waits, poor communication, lack of transparency, and significant emotional and health impacts. It reports that families want to be informed, involved, and treated with empathy and respect. Addressing these concerns is essential for restoring trust and improving outcomes for children. In response to the narrative review, CHI has developed a Quality Improvement Plan with 26 actions of which 65% are complete, and 35% are partially complete.

The HSE and Department of Health have an improvement programme and established an National Oversight Improvement Steering Group for Children’s Health Ireland to ensure any crossovers related to a number of reports are connected and integrated to achieve maximum benefit including evidence based updates in respect of recommendations across HIQA and a number of internal reviews fully or partially completed. CHI has achieved a 6% and 8.5% improvement in OPD and Inpatient and Day Case (IPDC), including spinal waiting times respectively to end of 2025.

This important work is providing better oversight and integration and that coupled with strengthening of the CHI Board, new appointments to the senior leadership of CHI, including a new CEO appointed in January 2025 and the decision by the Minister to formally integrate CHI into the HSE ensure there is sustained leadership and oversight.

Anne O’Connor, CEO of the HSE said, “I would like to acknowledge the work that has been undertaken to review and finalise this important work. The HSE recognise the importance of sustained reform to ensure safe, timely, and equitable access to care for children and young people. The review does not identify evidence of inequity in access to care and this is important. It finds key areas for improvement including waiting list governance, documentation, data quality, funded initiatives and related assurance processes. The report highlights breaches in clinically recommended timeframes and the impact for children and their families. Progress is expected to reduce waiting times, improved patient flow and timely access to care for children and these recommendations are being considered by the HSE nationally for system wide learning for all regions.  The narrative review highlights systemic issues affecting paediatric patients and families and their experience on waiting lists and engaging with clinical and operational services.

The HSE requires full implementation of all recommendations outlined in the documents published today and provide it with evidence-based assurance as CHI continues to address waiting times, organisational transition, to the National Children’s Hospital Ireland and integration with HSE systems.”

Kate Killeen White, REO HSE Dublin and Midlands said, “The HSE acknowledges the progress made to date by CHI and recognises the complexity of the changes required. However, the urgency of addressing paediatric waiting lists cannot be overstated. The implementation of these report recommendations represents a critical opportunity to strengthen systems, improve patient safety, and restore public confidence. The HSE remains committed to deliver governance assurance and work collaboratively with CHI to ensure that all children receive timely, safe, and appropriate care. We acknowledge the experience of those families that have contributed to this review and what that means for patients and families who attend services every day. Continued efforts by clinical, nursing, administrative and management teams to respond to these stories and improve access to care for children is a real opportunity for change.”

Lucy Nugent, CEO CHI said, “I would like to acknowledge the experience of the patients and staff captured in the narrative report and to state without reservation that we, CHI, need to continue to improve communication with families and to improve processes and to continue to improve access times. These reports identify areas requiring improvement in terms of waiting list governance, data, documentation and communication processes for families. The recommendations arising from both reports have been prioritised and are either fully or partially complete. During and after the review period, CHI has also progressed a number of important enabling developments, including the continued roll-out of the Central Referrals Office (CRO), preparation for implementation of the Electronic Health Record (EHR), consolidation and standardisation of policy management through Q-Pulse and strengthening of Clinical Specialty Lead (CSL) roles.”

There are 31 recommendations set out in the audit report (32 actions) which are designed to support a structured strengthening of governance, data, and control arrangements and patient engagement and experience across CHI. These include the establishment of standardised frameworks, improved documentation and data governance, and enhanced oversight of funded activity and consultant arrangements. In addition to the recommendations in the narrative report the following are in progress including patient communication policies, OPD patient experience survey and ongoing work with their Family Advisory Network. Immediate actions have been taken to rectify these identified areas, with further systemic improvements underway.

The HSE and CHI are committed to continuing with a programme of audit and assurance as it works to rebuild trust and confidence in national paediatric services.