Deficits surrounding Letterkenny University Hospital’s gynaecology service have raised further questions about oversight, governance and accountability in the hospital system, as well as political commitment to resolving ongoing staffing issues in healthcare. Catherine Reilly reports.
In October 2021, HIQA stated it was “not assured” there were sufficient and effective governance and oversight arrangements in place to assure the quality and safety of the gynaecology service in Letterkeny University Hospital (LUH), after conducting an extensive review.
Initial concerns were raised with HIQA in 2018 in regard to failings surrounding the service, which have resulted in women receiving delayed diagnoses of endometrial cancer and some dying with the condition. According to HIQA, since that time, it had “engaged” with LUH, Saolta University Health Care Group and the HSE at a national level about gynaecology services at the hospital.
An Authority spokesperson informed the Medical Independent (MI) it was “continuing to engage” with Saolta “to monitor the progress of implementation of measures to address the governance and quality issues identified” in its review.
The review found that LUH and Saolta were substantially supported and resourced to implement recommendations from an external review of the gynaecology service, which was commissioned by Saolta and published in 2020 (the Price report).
With the support and guidance of a special measures team (SMT), HIQA acknowledged “some important changes and initiatives had been introduced to improve efficiencies and the quality, safety and reliability of gynaecology services”. However the impact of these changes “had yet to be fully realised”.
The Price report was commissioned to assess the quality and safety of the gynaecology service in response to eight instances of delayed diagnosis in women with endometrial cancer. It found poor follow-up practices in the referral, assessment, and diagnosis processes for women referred to LUH’s gynaecology services with post-menopausal bleeding; increasing waiting lists, which impacted on timely access to services; poorly defined and inefficient care pathways; and an overall poor approach to the governance and oversight of gynaecology services at the hospital. It issued six main recommendations.
Despite the Price report being commissioned by Saolta, in an addendum the authors expressed their dissatisfaction that LUH and Saolta did not inform them that a histology audit was occurring in parallel, which examined endometrial cancers diagnosed at LUH between 2010 and 2019. This audit referred to 133 women diagnosed with endometrial cancer, and 38 women waiting longer than 100 days from initial referral to diagnosis.
While the Price report noted evidence of structures and processes in place in relation to the governance for quality and safety of the gynaecology service, “significant effort” was required to improve the robustness of the “governance processes which support the governance structures”.
A spokesperson for Saolta informed MI “we are aware of the need for strong governance structures across all services in our hospitals and the wider Group”.
“Late last year the Group engaged with an NHS team on some short preliminary work to support the rollout of further service improvements in LUH and the Saolta Group. As a result of their own service pressures, they were unable to continue with this process.
“However, we will be using the output from this process as part of further work which we are now progressing. Saolta has now engaged a team from EY which has begun a process of work focusing on change management processes and governance.”
This work will be the latest in a series of internal and external reviews and assessments pertaining to the gynaecology service and associated governance and quality assurance structures and processes.
Another of these mechanisms, albeit one which had a limited remit, was a national oversight group established by the HSE to assess whether the recommendations in the Price report were being implemented adequately at LUH.
Minutes of seven meetings of the oversight group from 14 July 2020 to 8 April 2021, obtained from the HSE under Freedom of Information law, showed dissatisfaction about the level of engagement with the group from the Saolta executive and ongoing attempts to gain more detailed information, including on reporting structures and relationships, and specific barriers and facilitators to implementation of the Price recommendations.
The oversight group, which reported to the HSE Chief Operations Officer (COO) Ms Anne O’Connor and HSE Chief Clinical Officer (CCO) Dr Colm Henry, was chaired by Prof Keelin O’Donoghue, Consultant Obstetrician and Gynaecologist at Cork University Maternity Hospital.
Members included HSE National Director of Acute Operations Mr Liam Woods, Clinical Lead of the HSE National Women and Infants Health Programme (NWIHP) Dr Peter McKenna, and the then Chair of the Institute of Obstetricians and Gynaecologists (IOG) Dr Cliona Murphy. During a separate section of the meeting, senior representatives from Saolta joined to provide updates and take questions from the group.
Minutes of meetings indicated that members of the oversight group sought to forensically examine Saolta and LUH’s progress in implementing the six recommendations in the Price report. However, the group never conducted a site visit as was intended, with an inhibiting factor appearing to be the pandemic’s impact in LUH.
The unsuccessful recruitment of consultants raises concern about the gynaecology services in LUH
At the group’s second meeting in August 2020, the Chair Prof O’Donoghue advised she had sought an initial informal meeting with the SMT during an unrelated visit to LUH regarding implementation of bereavement standards in maternity services.
The SMT was deployed by Saolta in July 2020 to provide clinical and administrative guidance and support in implementing the Price report recommendations. However, the SMT was advised by Saolta management they should not meet with Prof O’Donoghue during her visit, according to minutes.
In October 2020, at its third meeting, the group discussed a response from the Saolta executive regarding information it had requested. The group agreed that “an overarching and comprehensive plan is still required to establish the strategy of the gynae service in LUH”.
Mr Woods, National Director of Acute Operations, commented that the “resource requirements for LUH need to be identified and noted in the context of the overall strategic report. When the special measures team (SMT) departs, will the improvements be sustained?”
At a meeting in November 2020, the oversight group noted the “comprehensive implementation plan” it had received from Saolta. However, it continued to raise concerns about the “dependency” on the SMT for the implementation process. Dr McKenna, Clinical Director of the NWIHP, “articulated that following review of the implementation plan, it was still unclear what the root causes of the problems are in LUH and how the situation has developed to what we see outlined in the Saolta report. All the group agreed this is a major concern.”
At a meeting in December, Prof O’Donoghue discussed a letter issued to the Saolta CEO Mr Tony Canavan and the oversight group’s requests for updates on plans concerning the SMT, minutes of the LUH gynaecology service implementation group, the overall funding request, and the implementation tracker.
Mr Canavan’s response had “requested clarity” on the oversight group’s role/responsibility, the “level of information required”, and the “purpose” of a planned site visit.
At the oversight group’s meeting in February 2021, Ms Margaret Brennan, HSE Assistant National Director, Quality and Patient Safety Lead, Acute Operations, noted that there was “limited assurance by Saolta HG re addressing recommendations from the Price report. There appears to be a disproportionate focus on inpatient and day case capacity, rather than causes of the delayed diagnosis that led to the report ie, triage, waiting list management, governance, communication, training and education, and leadership.”
Mr Killian McGrane, Director at NWIHP, “concurred” and “noted the impact of culture on the implementation of the Price report. The unsuccessful recruitment of consultants raises concern about the gynaecology services in LUH.”
At the penultimate meeting of the oversight group in April 2021, Mr Woods expressed the view that the group’s terms of reference were technically nearing completion. The possibility of finalising the group’s work had been raised at the previous meeting in the absence of Mr Woods.
While some disquiet was expressed at the timing of this move, MI understands there was also concern that the group would continue for a protracted period with limited impact.
Ms Louise Loughlin, National Manager of the National Advocacy Service, was concerned about the impact of the oversight group stepping back at this stage. She also commented that “Saolta HG never fully engaged with the process”. During the meeting, Mr Woods observed that a “local grasp of challenges and change in culture is required by senior management and clinicians at LUH”.
Over the course of its discussions, the oversight group had acknowledged the efforts of staff working to implement change, including Prof John Morrison, Director of the Women’s and Children’s Managed Clinical and Academic Network (MCAN) at Saolta.
In conclusion, the group was not assured that all of the Price report recommendations were being adequately implemented.
“The group acknowledges there have been improvements in service but not at a satisfactory level to provide reassurance. All members recognise the commitment and work of Saolta HG and the SMT. Nonetheless, concerns remain that the underlying reasons for the current issues at LUH have not been fully addressed, and further, that improvements made through the MCAN/ SMT’s work will not be sustainable once the SMT is removed.”
The group prepared a close-out report which was finalised at a meeting in June 2021. In final correspondence to the HSE COO, Chair Prof O’Donoghue expressed her view that the Saolta executive did not engage fully with the process, preferring to report along usual management lines in the HSE. According to Prof O’Donoghue, it seemed there were multiple structures/levels of management structures in Saolta responsible for gynaecology services at LUH, but it was unclear which managers and clinicians at LUH were accountable for the change management processes involved.
Prof O’Donoghue also drew attention to consultant recruitment difficulties, a matter raised recurrently at the oversight group, including by Saolta representatives. She acknowledged there were certain issues that Saolta could not resolve alone.
More broadly Prof O’Donoghue noted that there seemed to be no national plan to address consultant recruitment challenges in model 3 hospitals (the HSE has since committed in its National Service Plan 2022 to examine this issue).
Prof O’Donoghue outlined that some of the issues at LUH may also be found in other similar-sized, model 3 hospitals nationally. She also noted that provision of a wide range of specialty obstetrics and gynaecology services in all these units would appear unrealistic and unsustainable into the future.
In her correspondence, Prof O’Donoghue suggested the establishment of a national working party for the review of gynaecology services across all units and development of a strategy for delivery of these services.
HIQA review
In spring 2021 the HSE’s oversight group was effectively stood down and, separately, Saolta withdrew the SMT from Letterkenny. At this juncture, HIQA began its review of governance of the hospital’s gynaecology service, which lasted until September 2021.
HIQA established that the hospital failed to meet national HSE and Saolta guidance and timelines for the review, testing and diagnosis of some women referred with post-menopausal bleeding, which were set following the Price report. Furthermore, Saolta failed to identify cases where non-adherence to timelines had occurred. This was “of significant concern to HIQA and was raised with the Hospital Group”.
The Authority also noted that LUH continued to struggle to recruit and retain medical, nursing, midwifery and administrative staff “which remains a risk to patient safety”.
The review acknowledged the introduction of a new ambulatory gynaecology model of care at the hospital in March 2021. However, it was not fully established and working at half of potential capacity at the time of review.
According to the HIQA report: “It was evident that the special measures team had an important role in leading and driving the changes to achieve efficiencies in the service….”
“However, when the special measures team was stood down in April 2021, HIQA was not assured that the necessary leadership was in place at Saolta Group level and Letterkenny University Hospital to continue to drive the necessary changes and efficiencies in order to ensure an effective, well-governed service. This was further confirmed by the commissioning of an external, independent intervention by the Saolta Group to review and make recommendations to improve governance and management at the hospital.”
If sustainable improvements in the governance structures and processes at hospital level and quality assurance mechanisms at Saolta Group level were not achieved with this further external intervention, then Saolta needed “to be held to account by the HSE”, it stated.
MI asked the Authority what being ‘held to account’ may entail. Its spokesperson commented: “As a follow up to findings in Letterkenny University Hospital, HIQA escalated its concerns regarding the governance structure and processes and quality assurance mechanisms to senior management within the national HSE.”
“The HSE is accountable for the quality of delivery in its own services against its own agreed standards of performance, as set out in the performance and accountability framework (2020).”
Saolta response
According to Saolta, it has been progressing implementation of the Price report recommendations through an implementation group convened in September 2020. “There are processes on site aligned to the HSE framework to ensure safety and quality, metrics are monitored monthly within the MCAN and Group-level oversight continues.”
On level of engagement with the HSE oversight group, Saolta maintained the request to meet the SMT “predated the formal establishment of the oversight group and the initial meeting with the Saolta Group executive team. Once the national oversight team was established, regular meetings were facilitated with the Saolta Group including members of the special measures team. The oversight group were offered opportunities to visit LUH.”
In regard to HIQA’s finding of limited evidence of engagement with women accessing the gynaecology service, Saolta stated that patient/service user representatives have been involved in the implementation group and a gynaecology patient forum is being established, with the first meeting scheduled for April 2022.
The spokesperson said the ambulatory gynaecology service was “fully implemented and meets the demand for this service in a timely and effective manner”.
Asked if any further cases of delayed or missed diagnosis of endometrial cancer at LUH had emerged since publication of the Price report, the spokesperson said Saolta was not aware of any such cases. “Any situation that arises where an acceptable standard of care is not met is investigated and managed through our Group-level quality and safety processes.”
Asked about LUH’s level of compliance with targets for the timely review and diagnosis of women referred to the hospital with post-menopausal bleeding, the spokesperson said: “All women are offered the clinic appointment within 28 days of referral and histology is available for over 90 per cent within 12 weeks. There are specific reasons for any woman falling outside of these timelines, eg, patient requested cancellations.”
At the time of HIQA’s review, five of the 14 risks recorded on the Saolta Women’s and Children’s MCAN risk register related to gynaecology services in the Group. These included delayed diagnosis and treatment due to insufficient capacity; dual governance processes during trial of concept of MCAN; access to operating theatres; difficulty in recruiting and retaining appropriately qualified and skilled clinical staff across the MCAN; and risks associated with reliance on agency and locum senior clinical decision-makers.
The spokesperson said the risks documented in the HIQA report remain for the Saolta sites.
Currently there are six approved consultant posts in obstetrics/gynaecology for the service in LUH, stated the spokesperson. Three consultants are in permanent posts and a fourth will be permanently appointed following recent interviews. There are two locum consultants working at the site and recruitment to fill these roles permanently is continuing.
HSE
A HSE spokesperson said: “The Saolta Group have provided assurance with regard to the safety of the gynaecology service at LUH. The assurance is supported by the very significantly reduced numbers of patients waiting to be seen at OPD [outpatient department] or waiting for procedures. The assurance is also supported by the ongoing audit of OPD referrals. The CEO of Saolta reports to National Director of HSE Acute Operations. Performance is monitored through monthly performance meetings.”
The spokesperson said that, following the submission of the findings of the oversight group in its report back to its sponsor (the HSE COO), it was “agreed that a more effective method of monitoring and assuring progress on the implementation of the remaining recommendations at that stage was to return to the normal operational management line”.
The NWIHP is currently developing an “integrated workforce plan for maternity services” which includes consultant obstetricians and gynaecologists.
“This plan is at an early stage of development. A group has been established and this group is working with the HSE Workforce Planning Unit.”
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