Patients in the Southern Health Trust were failed amid systemic failures across governance, oversight, leadership, culture and board accountability, the Urology Services Inquiry has found.
The probe set out to examine governance around urology services in the trust after concerns were raised around the clinical practice of hospital consultant, Aidan O’Brien who is retired from the trust.
The probe, ordered by former health minister Robin Swann in 2020, found on Wednesday that patients suffered serious harm, including failures in diagnosis, treatment and follow up.
It also identified repeated missed opportunities to act on a doctor in difficulty, with risks not addressed and that weak systems failed to identify and act on risk early.
The issues were found to have been deep rooted across the trust beyond one clinician.
Mr O’Brien was found to have been a skilled surgeon who did not set out to cause harm, and the inquiry noted the trust “failed to recognise that he was a doctor in difficulty and failed to manage him appropriately”.
The inquiry has made three core recommendations, including that patient safety must be primary purpose, to strengthen leadership, and improve use of data to identify and act on risk.
Chairwoman of the Inquiry, Christine Smith KC, said patients were “badly let down”.
“At its heart, this report is about patients who were badly let down,” she said.
“They faced delays in diagnosis and treatment, including cancer care, poor communication, and too often they were left without the clear, high-quality, timely interventions they should have expected.
“Our task was to understand how that harm occurred and why it was not recognised or addressed.
“The inquiry makes clear that the deeper causes were systemic.
“Weak governance, poor oversight, ineffective escalation and underdeveloped leadership created the conditions in which patients could come to harm.
“Put simply, there was a failure to recognise risk early and to respond to it properly.”
Turning to Mr O’Brien, Ms Smith said issues about his practice were known for years, but were never satisfactorily addressed.
“Warning signs were missed, and opportunities to act were not taken soon enough,” she said.
“However, this report is not simply about one doctor. It highlights wider systemic failings, where risks were not escalated, concerns were not acted upon, and opportunities to prevent harm were missed across the Trust.
“Stronger systems of governance would have enabled earlier detection and more effective intervention.”
The inquiry recognised that improvements have been made since these issues came to light, including changes within the trust and wider work led by the Department of Health.
However, it found it is clear that further, sustained and transformational change is required.
Its recommendations are aimed at strengthening patient safety across the system.
They are the formal declaration of patient safety as the dominant and primary purpose of healthcare, a comprehensive leadership development programme across the system and sustained investment in data and information.
Ms Smith said the recommendations are aimed at “strengthening leadership, governance, culture and accountability across the system, so that patient safety is not simply an expression, but the clear and constant priority”.
“This requires greater insight into patient outcomes, harm, experience and service performance, with risks identified earlier and acted on more effectively,” she said.
“While we recognise the progress that has been made, further change is required.
“We urge those responsible for implementing these recommendations to embrace this report as an opportunity to deliver meaningful, lasting improvements in patient safety.”
The health minister Mike Nesbitt offered an “unconditional apology”, saying it is the second time he has done so in a week after the Muckamore Abbey Hospital Inquiry last week found “profound and deeply troubling” failures at a facility for vulnerable adults.
Speaking to reporters outside the Department of Health in Belfast, Mr Nesbitt said: “The main conclusion for me is that patients suffered serious harm, both in terms of diagnosis, treatment, and also in follow-up.
“And when I look at the conclusions from the Muckamore public inquiry last week, and this inquiry, I do see some themes.
“For example, in terms of leadership, a lack of curiosity, basic curiosity, asking what is happening, what is being done to fix things when they go wrong.”
Mr Nesbitt said the health system has to “rebuild that confidence” with service users, and to that end he had called a health summit with all chairs and chief executives across the HSE.
“I will be saying to them, ‘You have a lot of priorities, there is a push pull in terms of save me money but deliver better services, but above all that at the top of the pyramid is patient safety, patient safety, patient safety – this is the end’,” he said.
The chair of the inquiry had also referred to a “mandated” duty of candour, which was raised last week as a recommendation from Muckamore.
In a healthcare setting, the duty of candour would obligate providers to be open, honest, and transparent with patients or their families about care and treatment.
The Health Minister said he would like to see the duty of candour “for debate” on the floor of the Assembly before the end of the current mandate in May 2027, but that is “wedded” to the UK Government’s long-awaited Hillsborough Law.
