Action Plan & Progress Reports - HIQA Review - Ms. A - University Hospital Galway

The Health Service Executive (HSE) published the implementation plan for recommendations of the investigation by the Health Information and Quality Authority (HIQA) into the provision of services to Ms A by the Health Service Executive at University Hospital Galway in relation to her symptomatic breast disease, and the provision of Pathology and Symptomatic Breast Disease Services by the HSE at the Hospital.

This implementation plan relates to the second investigation undertaken by HIQA into services provided by the HSE.  Progress on implementation of the recommendations arising from the first HIQA investigation, relating to care provided to Ms. Rebecca O’Malley, is also available.

The HSE is dedicated to delivering a health service where everyone has easy access to high quality care that they can have confidence in and that staff are proud to provide.  We would like apologise to the patient at the centre of the investigation, referred to as Ms. A, and her family for their experience of care provided by the HSE.  Ms. A was assessed for symptomatic breast disease at a private facility, Barrington’s Hospital in Limerick.  Services at that hospital were investigated by the Department of Health and Children and the findings of this review are published in the ‘Report on the Independent Review of Symptomatic Breast Care Services at Barrington’s Hospital, Limerick’.  Pathology samples taken on two separate occasions from Ms. A were reviewed at Galway University Hospital, and on both occasions these samples were the subject of interpretative errors by two different pathologists.  In the course of the investigation, interpretative errors were identified in the work of a pathologist, referred to as Dr. C, employed on a locum basis at Galway University Hospital.  The HSE would also like to apologise to patients and their families who were impacted by these errors.  

The investigation concluded that the clinical performance of Dr. C with regard to his cytology and histology practice was weak.  However, the investigation also identified a number of weaknesses in the clinical, managerial and governance systems operating in the hospital and between the hospital and the private facility which contributed to the incident.  While the investigation focused on Galway University Hospital, the system weaknesses identified are of relevance across services provided or funded by the HSE.  The report of the investigation made twelve recommendations which provide the HSE with a focus for continuing to improve the quality and safety of services on a national basis.

The HSE is committed to learning from adverse events.  It strives to apply this learning to deliver sustainable improvement across the system which will lead to safer, better care for the benefit of patients.  The HSE is already openly demonstrating this commitment through its work on implementing the recommendations from the report on the first HIQA investigation, relating to care provided to Ms. Rebecca O’Malley.  The HSE is making updates on the progress of the implementation of the recommendations in that report public by publishing them on the HSE website

The HSE is publishing its plan to implement recommendations arising from this second HIQA investigation.  The improvements which will follow from the implementation of these recommendations will ensure that patients and their families can feel safe in our care and be confident that the services they receive will provide them with the best possible outcomes.  The implementation plan was developed by the HSE and submitted to the Department of Health & Children and HIQA for consideration.  It was approved by the Senior Management Team of the HSE and presented to the Risk Committee of the Board of the HSE.

The HSE will be reporting on progress on the implementation of the plan to the Risk Committee of the Board of the HSE. Progress reports will be made publicly available on a quarterly basis from 2009 and will be published on this page.

You can read or download this report on this page.

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