HIQA has issued a damning report following its statutory review into the governance and oversight of surgical implants at Children’s Health Ireland (CHI). The review was prompted by public concern after three children received unapproved, non-CE marked metal springs during spinal surgeries intended to treat scoliosis at CHI at Temple Street Hospital, Dublin.
HIQA found that the springs were used in an attempt to replicate, in a modified manner, an experimental technique under investigation abroad.
Their use also occurred without ethical approval or documented managerial sign-off. Critically, families were not properly informed of the experimental nature of the procedures, breaching the HSE National Consent Policy (2013).
The report concluded that “the use of the springs in this manner should not have happened”. It cited failures in procurement, decontamination, and communication processes. Governance structures were described as overly complex, with unclear lines of accountability following CHI’s 2019 establishment, undermining safe oversight of the orthopaedic service.
HIQA’s Director of Healthcare Regulation, Mr Sean Egan, stated: “Children were not protected from the risk of harm. Key lessons must be learned, not just within CHI, but across the national health service.”
The springs were implanted between 2020 and 2022, despite being made of non-alloyed spring steel – material not intended for surgical use. HIQA also highlighted long-standing issues within the orthopaedic team, including poor communication and dysfunctional dynamics, which contributed to the absence of vital safety checks.
In total, HIQA has made 19 recommendations: Nine directed at CHI; nine for HSE-funded services nationally; and one applicable to both public and private hospitals. These focus on tightening oversight and consent processes, clarifying reporting lines, and ensuring any new surgical techniques undergo robust ethical and safety reviews.
In her response to the report, the Minister for Health Jennifer Carroll MacNeill said: “I want to begin by apologising to the three young children and their families. What happened was wrong, should not have happened, and should not have been allowed to happen.”
“As patients and parents, we put our trust in healthcare professionals. That is particularly the case here where parents had put their trust in clinicians to treat their very sick children. This HIQA report is clear that their trust was breached in this case. These children were not protected from the risk of harm, as they should have been.
“Yesterday, I met with both the Chief Executive and Chairperson of Children’s Health Ireland. We discussed the report, its findings, and the recommendations. I made very clear to them my deep disquiet at what happened here and my clear expectations in terms of reform and change to ensure it does not happen again”
The Minister noted both CHI and the HSE have accepted the recommendations of the review.
Commenting on the report, HSE CEO Mr Bernard Gloster said: “What happened here was wrong and unacceptable. Given the role of the HSE in funding CHI, I want to offer a sincere and unequivocal apology to the children and families affected by these issues. I will be requesting an early meeting with the board and executive of CHI to set out our clear expectations in all matters of governance and oversight.”
The full report is available on www.hiqa.ie.
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