Urology patients died due to failures in their care, inquiry finds
Some patients under the care of a consultant urologist in the Southern Health Trust died as a result of failures in patient care, the Urology Services Inquiry has found.
Christine Smith KC said systemic failures, weak governance, poor oversight and underdeveloped leadership created "conditions in which patients were seriously harmed".
She said patients of the consultant, Aidan O'Brien, were badly let down, facing delays in diagnosis and treatment, including cancer care.
The chief executive of the Southern Health Trust, Steve Spoerry, has apologised adding he "completely accepts that patients came to harm".
"The treatment of patients was in some cases delayed, diagnosis was delayed and that would have lead to worse outcomes - worse outcomes in terms of symptoms and potentially premature death," he said.
The inquiry was set up in 2020 following a series of Serious Adverse Incidents (SAIs) involving O'Brien.
Urology is a part of health care that deals with diseases of the male and female urinary tract including kidneys, bladder and urethra.
The problem first came to light in October 2020 when the records of more than 1,000 patients who were in the care of O'Brien were recalled at the Southern Trust.
The inquiry looked at O'Brien's work at the trust between January 2019 and June 2020 and also focused on the Southern Trust's handling of urology services before May 2020.
O'Brien is now retired.
The report sets out clear recommendations to strengthen leadership, governance and culture, and to ensure failures are not repeated.
The Urology Services Inquiry found that there was both a failure of individual responsibility as well as systemic failures.
While the report reviews O'Brien's practice, it is scathing in how systems were managed, led and the lack of accountability from the health trust board.
Christine Smith KC said that O'Brien was a skilled surgeon "who did not set out to cause harm", but the trust "failed to recognise that he was a doctor in difficulty and failed to manage him appropriately".
The report said concerns about O'Brien's practice were known for many years before 2016, including triage delays, record-keeping failures, storage of patients notes at home, delayed dictation, non-standard prescribing and other clinical and administrative concerns.
It said medical and operational management did not consistently recognise that issues labelled as 'administrative' could amount to significant patient safety risks.
It added that the prolonged failure to triage referrals properly created a clear risk that urgent cases, including cancer cases, would not be identified or escalated in time.
The inquiry also found that the trust ought to have recognised that O'Brien was at points a doctor in difficulty and managed him as such, with a formal support and improvement plan, rather than repeated tolerance of unsolved risk.
Key findings include:
Patients suffered serious harm, including failures in diagnosis, treatment and follow up
Patients suffered serious harm, including failures in diagnosis, treatment and follow up
Repeated missed opportunities to act on a doctor in difficulty, with risks not addressed
Repeated missed opportunities to act on a doctor in difficulty, with risks not addressed
Weak systems failed to identify and act on risk early
Weak systems failed to identify and act on risk early
Systemic failures in governance, oversight, leadership, culture and Board accountability
Systemic failures in governance, oversight, leadership, culture and Board accountability
Three core recommendations:
Patient safety must be primary purpose
Patient safety must be primary purpose
Strengthen leadership
Strengthen leadership
Improve use of data to identify and act on risk
Improve use of data to identify and act on risk
Smith said the report is about patients who were "badly let down".
"They faced delays in diagnosis and treatment including cancer care, poor communication and too often they were left without the clear high-quality, timely intervention they should have expected.
"The inquiry makes clear that the deeper causes were systemic.
"Weak governance, poor oversight, ineffective escalation, and underdeveloped leadership created the conditions in which patients were seriously harmed," the chair added.
'Line in the sand'
Health Minister Mike Nesbitt said "for the second time in less than a working week I find myself having to offer an unconditional apology for something that has gone incredible badly wrong in health care delivery.
"This was failure of monumental size."
He said, as with the findings of the Muckamore inquiry, there seemed to be a "lack of basic curiosity" from leadership "asking what is happening, what is being done to fix things when they go wrong?".
Nesbitt said that "every avoidable death is a tragedy and I apologise for it".
"What I'm saying clearly is we have had the last of these public inquiry reports over the space of the last number of days.
"It's a line in the sand - no more.
"My determination, which I will deliver to the leaders of health and social care on Tuesday, is line in the sand, put patient care your number one, number two, number three priority."
'Avoid repeating mistakes'
In a joint statement the Health and Social Care (HSC) system leaders said their thoughts are with the patients and families impacted.
"The inquiry focused on patient safety and these recommendations will help all Trusts in Northern Ireland avoid repeating past mistakes to ensure that other patients do not suffer harm," they said.
The inquiry did not determine criminal or civil liability or make findings on fitness to practice.
It examined how that harm occurred, why it was not fully recognised, and what changes are required to ensure safer care in the future.
It finished gathering evidence two years ago after hearing from 75 witnesses and receiving 650,000 pages of written evidence.
Aidan O'Brien was referred by the GMC for a hearing at the Medical Practitioners Tribunal Service (MPTS), for a tribunal to hear all the evidence, and make an independent decision about the doctor's fitness to practise.
This process is still ongoing.
The inquiry recognised that improvements have been made since these issues came to light, including changes within the trust and wider work led by the Department of Health.
But it said it is clear that further, sustained and transformational change is required.
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