CHI chief’s summary of problems at Temple Street fails to answer the question why

Following publication of this article, The Irish Times was informed that the version of the report referred to in our piece was an initial working draft and not the final version. That draft was withdrawn by Children’s Hospital Ireland on August 17th, 2021 on the basis that it contained inaccuracies. CHI apologised for these inaccuracies and requested that all copies of the earlier draft be destroyed. Revised drafts were issued in the weeks that followed. None of these versions of the report contained the name of Mr Connor Green or singled him out for personal criticism. We are happy to clarify this.

“Things happened at Temple Street that should not have happened,” Children’s Health Ireland (CHI) chief executive Eilish Hardiman told TDs last September, just after the scandal at the orthopaedic unit of the hospital had broken.

She gave the Oireachtas health committee a summary of the problems at the unit. “Decisions were made, certain procedures were carried out, children were subjected to a higher-than-expected number of unplanned return trips to theatre and, alarmingly, unapproved, non-medical-grade devices were implanted in three children.”

It was, she told the politicians in her opening statement, “a shocking litany of events”.

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But missing in Hardiman’s account was an explanation of why these events occurred; why 13 children needed further unplanned surgery; why one child died; and why unauthorised springs were implanted in three children during complex spinal surgery.

These are the questions families want answered; yet, they have been told, answers must wait until a variety of reviews and investigations into the fiasco are completed.

One of the central questions to be answered is whether the problems in Temple Street resulted from the actions of one consultant, or whether wider factors were at play. Another is whether enough was done, sufficiently early, to limit the damage to patients.

[ Temple Street managers gave warning about surgeon’s competence a year before serious incidents ]

In announcing an external review last September, the HSE said “an individual consultant” would be its primary focus. That consultant, who performed the most complex spinal operations on young children, Connor Green, has been placed clearly in the frame; named on social media and in court.

Green specialised in operating on very young children with progressive spine curvature. Failure to operate promptly can impact on their lungs, leading to death. Treatment often involves implanting metal rods to straighten the spine, which can be lengthened as they grow, but this is highly complex surgery.

The reviews that have been done so far pointed to high levels of post-operative complications for children with spina bifida who underwent spinal surgery. The assessment was based on international comparisons, but the published literature is sparse and even a few adverse outcomes could significantly alter a surgeon’s overall figures.

What of the wider context in which Green and his colleagues were operating? Was this a system that was doomed to fail, due to a mismatch between resources and demand for surgery?

[ Judge directs CHI to provide medical records over alleged ‘botched’ spinal surgery ]

A report obtained by The Irish Times, drawn up by senior Temple Street staff and furnished to CHI, shows there is a long backstory to the problems in the orthopaedic unit. CHI, which is responsible for the three Dublin children’s hospitals, was briefed about these problems and told to act on them.

As early as 2019, CHI management were told about “unacceptable behaviours” in the unit. The Covid-19 pandemic and HSE cyberattack undid progress in resolving issues by increasing pressures on staff and resources. By 2021, the problems had worsened again – the report refers to “numerous incidents of poor behaviours”, a “lack of professionalism” and “abusive conversations”.

Some of the causes are laid out in the report, and in an earlier draft. The five consultant orthopaedic surgeons in Temple Street had split commitments between Temple Street, Cappagh hospitals, the Mater hospital, the Central Remedial Clinic and the Rotunda hospital. That meant there were just 2.6 whole-time equivalents in Temple Street to meet the needs of an ever-growing list of patients awaiting surgery. And those five consultants shared just 3.5 days of theatre access a week, even before rolling closures due to Covid-19. A promised fifth operating theatre had failed to materialise.

“This deficiency has been one of the key drivers of conflict within the orthopaedic department which has not been addressed appropriately,” the draft report stated. The team “feel they are putting out fires all of the time”.

Temple Street management tried to deal with the situation by banging heads together; holding one-to-ones with staff and regular group meetings. This worked but only for a while. Green started bringing in urgent elective patients as emergencies over the weekend, with adverse impacts for other staff. Relationships within the unit deteriorated again.

[ Parents’ group calls for reinstatement of doctor at centre of spinal surgery controversy ]

Written in mid-2021, the report warned of a “real risk to patient safety and staff wellbeing” if the service issues were not addressed. Instead, they got worse, as Government pressure increased to speed up the rate at which surgeries were being performed. An additional €19 million was provided last year, but the extra money may only have served to increase the pressure on staff, given the wider resource issues.

The report also called for “poor interpersonal issues” in a “very fractured” team to be addressed. Without naming Green, it warned of the potential for a “significant never event given the poor communication and cavalier approach of one consultant”.

This is exactly what happened. A “never event” is defined as “a serious incident or error that should not occur if proper safety procedures are followed”. In July and September 2022, there were two surgical incidents involving children operated on by Green, described by the HSE as “particularly serious”.

The report paints a portrait of a dysfunctional department, with deep interpersonal tensions and staff scrapping over limited resources. Some families The Irish Times has spoken to are supportive of Green while others are critical; one mother recalled him “screaming” at other staff and “making a show” of a physiotherapist who tried to refer a patient to him.

The report recommended “CHI should consider an external review once CHI are clear on the parameters and options available to the organisation”. It should also “address CG personality, behavioural and surgical competence in working on significantly difficult case-mix in a multi-professional environment. Put in a programme to address the unprofessional behaviour and hold people to account.”

Green declined to talk to The Irish Times about the matters under review. His colleague Prof Damien McCormack told the Sunday Independent last month that Green was performing a “huge volume” of highly complex procedures with inadequate resources. According to Prof McCormack, he wanted to do fewer complex surgeries, but was told by hospital management to maintain his work rate.

Despite the controversies of recent months, support for Green remains strong among some of his patients. Last week, one of the many patient groups started a petition for his reinstatement.

The HSE-commissioned external review into the unit is due to report back initially by the end of the year.