Patient safety investigation report published

Date of publication:

The Health Information and Quality Authority today published the Report of the investigation into the quality and safety of services and supporting arrangements provided by the Health Service Executive at the Mid-Western Regional Hospital Ennis. The Board of the Authority approved the Report and authorised it for publication following a meeting on Monday 6 April 2009. 

The Investigation found that it is unsafe to keep the service configuration at the Mid-Western Regional Hospital (MWRH) Ennis as it currently is. However, there are significant opportunities for high quality, appropriate services to be provided at MWRH Ennis in the future but these must be safe for the benefit of the public.

The Investigation was triggered following serious patient safety concerns having been raised by family members of two patients – the late Ann Moriarty and the late Edel Kelly. At the outset of the Investigation, further patients and their family members approached the Authority with concerns relating to their care at the Hospital. The experiences of all the families who came forward informed and shaped the investigation. Through sharing their experiences, these families will benefit future patients and enable high quality, safer services to be provided at MWRH Ennis.

The Investigation found examples of good non-acute care being provided at MWRH Ennis and a committed ethos from Hospital staff. It also identified a range of services which could be greatly expanded and enhanced at the Hospital in the future, including diagnostic services, outpatients, day procedures, appropriate medical care, minor injuries and rehabilitation as part of the Regional Hospital Network.

Dr Tracey Cooper, Chief Executive of the Health Information and Quality Authority, said: “The Investigation found that the Hospital as it is currently configured is unsafe and will need to change the range and types of services it provides for its patients in order to build a thriving, appropriate and safer future for the community that it serves. It is therefore vitally important that the Health Service Executive sets about planning the implementation of all the recommendations contained in this Report, in conjunction with staff and local communities. Similarly, it is important to ensure that appropriate facilities, resources and staff are in place throughout the Mid-Western Hospital Network to effectively manage these changes safely.”

Diane Whittingham, the Chairperson of the Authority’s Investigation Team, said: “What has driven this investigation is a concern for safety and quality, and there are significant opportunities for high quality, appropriate services to be provided at MWRH Ennis in the future. To ensure that these services are fit for purpose, the HSE should, as a priority, undertake a review of the effective management, leadership and governance arrangements at Mid-Western Regional Hospital Limerick to ensure that appropriate arrangements are in place to guarantee the effective management and safe implementation of these changes. However, it is clear that it is unsafe to keep the current service configuration at MWRH Ennis and the changes recommended in this Report must happen in a safe and effective manner.”

The Report highlights a lack of clarity and accountability and that there is no single person at Hospital level who is fully accountable for the quality and safety of services.

The findings of the Report are informed by national and international evidence on how high quality services should be provided safely in order to ensure that patients are treated in the right place at the right time by the right professionals. The findings show that, in the interests of patient safety, the following services provided at MWRH Ennis must cease:

  • Acute, specialist, and complex surgical services, including cancer surgery
  • Critical care/intensive care services
  • 24-hour emergency department
  • Maternity services
  • Paediatric services.

Dr Alan McKinney, a member of the Authority’s Investigation Team, said: “International evidence shows that patients with certain conditions obtain safer and better outcomes when they are cared for in specialist centres by clinicians who are dealing with high volumes of work where they can maintain their expertise and provide a full multidisciplinary approach to care. In this context, acute services at MWRH Ennis are not sustainable because there are simply not enough patients presenting with acute, complex, or specialist conditions in order for clinicians to adequately maintain their clinical skills and to continue to provide safe care for these patients. The Investigation Team does not believe that additional resources deployed in seeking to sustain acute services at MWRH Ennis would be appropriate as it is ultimately unviable as an acute hospital.”

“The international evidence also shows that there is a move towards providing the maximum level of appropriate and safe services as near as possible to where people live. MWRH Ennis therefore has a future if a range of appropriate services are enhanced there,” he said.

Dr Cooper concluded: “The case for change has to be developed and communicated clearly and effectively to patients, the public and healthcare workers. The Authority will request the Health Service Executive to produce an implementation plan for the efficient, safe and effective implementation of the 65 recommendations contained within the Report and we look forward to working with it and all other stakeholders to driver safer services.”


Further Information: 

Marty Whelan, Head of Communications and Stakeholder Engagement 01 814 7481 / 086 2447 623