Office of the Chairman

Health Service Executive,

1st Floor,
Dr Steevens’ Hospital,
Dublin 8.
Tel: (01) 6352877
Fax: (01) 6352898

21st February 2007

Minister Mary Harney

Minister for Health & Children
Department of Health & Children
Hawkins House
Dublin 2

Dear Minister
I refer to your letter dated 27th November 2007 requesting the Board to undertake an immediate
review of the management of all events following the decision to suspend breast radiology service at
the Midland Regional Hospital, Portlaoise.

The HSE Board met on 27th November, 2007 to consider this request. It decided to establish a Board
Committee to finalise the terms of reference for the review and to engage an external independent
person to conduct it.

Terms of reference for the Review

The terms of reference for the review were drawn up by the Board Committee at its first meeting on
29th November 2007 and you confirmed by letter dated 14th December 2007 that these met the
requirements as set out in your letter on 27th November 2007.

External independent person engaged to conduct the Review

The review was directed by the Board Committee and, in accordance with the terms of reference, the
Committee appointed Mr. John Fitzgerald as the external independent person to conduct the review.
He was asked to determine the facts relating to:
• the manner in which the HSE dealt with patients throughout the period;
• the governance and management of all aspects of the process; and
• the communication arrangements with patients, internally within the HSE and with the
Department of the Health and Children.
1
Fitzgerald report

The report from Mr. Fitzgerald, which was accepted by the Board at its meeting on 21st February,
2008, is attached.

In accepting the report, the Board noted the finding by Mr. Fitzgerald that he did not identify any
suggestion of willful neglect by any individual/s involved in the process. However problems arose
from systemic weaknesses of governance, management and communications in dealing with the
situation that arose at Midland Regional Hospital Portlaoise during the period of the review.

Recommendations

In order that similar situations are handled appropriately in the future, the Board accepted the
recommendations proposed by the Committee that the following four key issues be given immediate
attention by HSE management:

1. The serious incident management protocol to guide the response to such adverse events,
which is currently being finalised, should be put in place throughout the HSE by management
as a matter of urgency. The purpose of this protocol is to clearly outline the procedures to be
followed when a serious incident occurs. In particular, the protocol should include guidelines
on the release of information during the response process. The protocol should apply to all
HSE staff and to those providing services on behalf of the HSE.

2. A clear management and governance process should be put in place by HSE management to
manage all aspects of a response to a serious incident. The process should be
overseen/directed by a member of the HSE senior management team with adequate dedicated
resources to facilitate the required level of response to support both the management of the
process and the clinical and administrative aspects of the response. The process must include
provision for establishing terms of reference and for communications with patients during the
progression of a response to the serious incident.

3. The process to be followed in each case should have as its absolute priority the position of the
patients involved over and above any other considerations.

4. Clarity should be established, at the outset of the response to the serious incident, by the
senior manager directing/overseeing the process, on who is to be involved from the HSE, the
Department of Health and Children and elsewhere (if applicable). Their precise roles and
responsibilities should be defined in writing. The HSE senior manager should take steps to
ensure the response to the serious incident is progressed with urgency and that a high level of

2
 engagement between the various parties is maintained throughout the response to the serious
incident.

The Board has requested the CEO to report back to it at its meeting in April 2008 on the progress
made in implementing these recommendations.

The Board also decided that, when the review of breast radiology services at the Midland Regional
Hospital Portlaoise is finalised and all the facts in relation to the events are available, the HSE will
make direct contact with patients to allow them express their feelings about the process.

Yours sincerely

______________
Liam Downey,
CHAIRMAN