Ennis report cuts to heart of deficiencies in small units

ANALYSIS: The implications of the damning report into Ennis Hospital go beyond the midwest; similar small hospitals elsewhere might also be a threat to patient health and safety

YESTERDAY’S REPORT by Hiqa, the Health Information and Quality Authority, into the quality of care at Ennis Hospital does not pull its punches: it concludes the hospital is unsafe for patients requiring acute medical care.

Triggered by the concerns of the families of two breast cancer patients – the late Ann Moriarty and the late Edel Kelly – the investigation went well beyond the specific issues raised by these families.

As a result, the Health Service Executive (HSE) has been told that “acute, complex and specialist services are not suitable for Ennis” and that the hospital does not have sufficient volumes of patients attending out of hours to justify a 24-hour emergency department.

The report found that no single person at the hospital was fully accountable for the safety of services there and that local clinical governance was limited.

Perhaps the most serious indication of problems at the hospital was the authority’s decision to write to the chief executive of the HSE in early January outlining the need to take immediate action to ensure the safe and timely referral of patients from the hospital.

It also asked the HSE to address urgently the quality of intensive care services at Ennis.

The implications of this report, however, go well beyond the midwest.

Minister for Health Mary Harney acknowledged this yesterday when she said: “I have asked the HSE to give careful consideration to the report’s conclusions and recommendations, not only in relation to Ennis, but to the delivery of acute hospital services generally.”

By concluding that Ennis hospital was unsafe for patients through a combination of inadequate consultant staffing levels, low patient throughput and by implication bed numbers, the report will put pressure on the HSE to identify other facilities that may suffer from the same shortcomings as Ennis.

Based on bed numbers alone, this suggests that hospitals in Dundalk, Roscommon, St John’s in Limerick and perhaps St Michael’s in Dún Laoghaire may have an uncertain future.

Of course, the quality of patient care is predicated on more than just bed and consultant numbers. It is possible for smaller facilities to function to an acceptable standard if they are part of a networked system that carefully defines the type of care they offer.

A key concept used to measure quality is the presence of “care pathways”. An integrated care pathway is a structured approach to patient care which details the essential steps to be provided by different professionals in the care of patients with a specific clinical problem. It ensures the right patients are cared for in the right way in the right setting.

However, when these pathways are patchy or non-existent, problems arise. In the case of Ennis, the report says it “also found examples of poorly co- ordinated care with key decisions on information about patients faltering in the gaps between systems, teams and departments”.

Both Ann Moriarty and Edel Kelly were the victims of unco- ordinated care. In the case of Moriarty, it was decided she needed a follow-up surgical consultation when she attended Ennis hospital on August 11th, but that never happened.

Abnormal blood test results – strongly suggestive of breast cancer recurrence – were filed in her chart without being acted on and it was unacceptable that it took 22 days for a chest X-ray to be read and reported on at Ennis General.

A key question must therefore be asked: what was happening to the daily flow of information about patients at Ennis?

It is indefensible to order a blood test for tumour markers (in itself a clear indication someone was concerned about cancer recurrence) and not follow up the result. Test results must never be filed without being signed off as either normal or requiring further specified action.

In Kelly’s case, the concern of a consultant pathologist who asked for further “clinical correlation”, even though the patient’s breast biopsy was negative for cancer, seemed not to have been responded to by clinical staff at Ennis. When the families and those of other patients were interviewed by the inquiry team, it emerged there had been communication difficulties between the families and staff in Ennis and also between staff and community services.

“This was especially the case in relation to the communication of clinical information required to ensure the safe and effective continuing care of the patient,” the report concludes.

In a significant recommendation on diagnostic services (X-ray and laboratory tests), the report advises: “A robust system for the safe, timely management and reporting of all tests both at local and regional laboratory level, should be developed, implemented and regularly audited.

“This system should involve the prioritisation of test reporting and protocols for the follow-up of the reports by the identified clinician.”

It is a pity the authority did not make this a national recommendation, as it did with some others, because it lies at the heart of the problems experienced by Moriarty and Kelly.

Without such a recommendation, can we be sure that doctors in other hospitals throughout the State are working in an environment that enables them to unfailingly feed back test results to patients and their family doctors? As things stand, every patient of our health service should make sure they ask for the result of every test performed on them and not simply rely on a general reassurance that “everything is fine”.

Despite the evidence that patients with certain conditions obtain safer and better outcomes when they are cared for in specialist centres, Ennis hospital must continue to look after people from Co Clare who suffer heart attacks, strokes and pneumonia.

As it is, most of Ennis’s 4,369 annual medical admissions are emergency cases with chest pain, lower respiratory tract infections, exacerbation of chronic bronchitis and urinary tract infections.

It is important to see patient safety at the top of the healthcare agenda. Notwithstanding funding difficulties, every one of the report’s 65 recommendations must be implemented.

Dr Muiris Houston is medical correspondent of The Irish Times