Holles Street, what's going on?

artfoley56

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in May 2016, Malak Thawley went into Holles St for surgery on an ectopic pregnancy and due to a "cascade of negligence" died on the operating table. The coroner returned a verdict of medical misadventure noting the lack of blood products and staff shortages

Holles Street then decided to have a one man internal review with no results published. Simon Harris asked the clinical lead of the National Women and Infants’ Programme Dr Peter McKenna to examine the coroner’s report and that of the National Maternity Hospital and to give an opinion on the “appropriateness of the clinical reviews which have been undertaken to date”. Jack Chambers TD raised the issue on behalf of the family. He said there were contradictions between the internal hospital inquiry and facts outlined by the hospital and where serious adverse incidents occur in hospitals, they should not be allowed to investigate themselves. Mr Chambers said the family believed that “crucial, vital and extremely revealing new facts, incidents and events have only now come to light”. He said the family believe the internal hospital review was a “shambolic attempt to hide crucial facts and salvage reputations”.

After this, the minister order HIQA to undertake a s9 review of Holles street and this review was yesterday challenged in the High Court when Holles st sought a JR of the minister's decision stating, on an ex parte basis, that "The particular type of review currently directed by the Minister for Health would be carried out under Section 9.2 of the Health Act, a section to be used only when the minister believes there is a serious risk to patients.This conveys to our staff and our patients that the minister believes that emergency surgical practice in this Hospital outside “core hours” is unsafe." the hospital also argues that the manner the inquiry is to be carried out would “have a chilling effect” on the delivery of high risk and emergency care at the hospital.

It's arguable that having people dying in your hospital , having an internal unpublished review and then getting out the lawyers when the agency charged with investigating these matters is instructed to investigate you would have even more of a chilling effect.

https://www.irishtimes.com/news/crime-and-law/courts/high-court/damages-paid-after-death-of-malak-thawley-at-holles-street-1.3357391

https://www.rte.ie/news/health/2018/0129/936797-holles-street/
so is Holles st being reasonable or is it the classic case of putting the institution ahead of learning the lessons and protecting the patient?
 


Spanner Island

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in May 2016, Malak Thawley went into Holles St for surgery on an ectopic pregnancy and due to a "cascade of negligence" died on the operating table. The coroner returned a verdict of medical misadventure noting the lack of blood products and staff shortages

Holles Street then decided to have a one man internal review with no results published. Simon Harris asked the clinical lead of the National Women and Infants’ Programme Dr Peter McKenna to examine the coroner’s report and that of the National Maternity Hospital and to give an opinion on the “appropriateness of the clinical reviews which have been undertaken to date”. Jack Chambers TD raised the issue on behalf of the family. He said there were contradictions between the internal hospital inquiry and facts outlined by the hospital and where serious adverse incidents occur in hospitals, they should not be allowed to investigate themselves. Mr Chambers said the family believed that “crucial, vital and extremely revealing new facts, incidents and events have only now come to light”. He said the family believe the internal hospital review was a “shambolic attempt to hide crucial facts and salvage reputations”.

After this, the minister order HIQA to undertake a s9 review of Holles street and this review was yesterday challenged in the High Court when Holles st sought a JR of the minister's decision stating, on an ex parte basis, that "The particular type of review currently directed by the Minister for Health would be carried out under Section 9.2 of the Health Act, a section to be used only when the minister believes there is a serious risk to patients.This conveys to our staff and our patients that the minister believes that emergency surgical practice in this Hospital outside “core hours” is unsafe." the hospital also argues that the manner the inquiry is to be carried out would “have a chilling effect” on the delivery of high risk and emergency care at the hospital.

It's arguable that having people dying in your hospital , having an internal unpublished review and then getting out the lawyers when the agency charged with investigating these matters is instructed to investigate you would have even more of a chilling effect.

https://www.irishtimes.com/news/crime-and-law/courts/high-court/damages-paid-after-death-of-malak-thawley-at-holles-street-1.3357391

https://www.rte.ie/news/health/2018/0129/936797-holles-street/
so is Holles st being reasonable or is it the classic case of putting the institution ahead of learning the lessons and protecting the patient?
That's it right there imo. It's the Irish way.

When I read that staff were dispatched to local pubs to get ice towards the end of this scandalous saga in a last ditch attempt to save Malak Thawley by freezing her brain... well... how any institution has the chutzpah to fail to put their hands up and admit full liability is beyond me... but this kind of galling arrogance and failure to accept full responsibility happens in Ireland all the time.
 

Mushroom

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in May 2016, Malak Thawley went into Holles St for surgery on an ectopic pregnancy and due to a "cascade of negligence" died on the operating table. The coroner returned a verdict of medical misadventure noting the lack of blood products and staff shortages

Holles Street then decided to have a one man internal review with no results published. Simon Harris asked the clinical lead of the National Women and Infants’ Programme Dr Peter McKenna to examine the coroner’s report and that of the National Maternity Hospital and to give an opinion on the “appropriateness of the clinical reviews which have been undertaken to date”. Jack Chambers TD raised the issue on behalf of the family. He said there were contradictions between the internal hospital inquiry and facts outlined by the hospital and where serious adverse incidents occur in hospitals, they should not be allowed to investigate themselves. Mr Chambers said the family believed that “crucial, vital and extremely revealing new facts, incidents and events have only now come to light”. He said the family believe the internal hospital review was a “shambolic attempt to hide crucial facts and salvage reputations”.

After this, the minister order HIQA to undertake a s9 review of Holles street and this review was yesterday challenged in the High Court when Holles st sought a JR of the minister's decision stating, on an ex parte basis, that "The particular type of review currently directed by the Minister for Health would be carried out under Section 9.2 of the Health Act, a section to be used only when the minister believes there is a serious risk to patients.This conveys to our staff and our patients that the minister believes that emergency surgical practice in this Hospital outside “core hours” is unsafe." the hospital also argues that the manner the inquiry is to be carried out would “have a chilling effect” on the delivery of high risk and emergency care at the hospital.

It's arguable that having people dying in your hospital , having an internal unpublished review and then getting out the lawyers when the agency charged with investigating these matters is instructed to investigate you would have even more of a chilling effect.

https://www.irishtimes.com/news/crime-and-law/courts/high-court/damages-paid-after-death-of-malak-thawley-at-holles-street-1.3357391

https://www.rte.ie/news/health/2018/0129/936797-holles-street/
so is Holles st being reasonable or is it the classic case of putting the institution ahead of learning the lessons and protecting the patient?
I note that you refer to "having people dying in your hospital" - so how many people and over what time frame?

What percentage of the "people" who attended the hospital "outside core hours" died. Is that percentage significant, or was the Thawley tragedy a complete outlier?

Answer those and I'll be in a more informed position to try to answer your OP.
 

Spanner Island

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I note that you refer to "having people dying in your hospital" - so how many people and over what time frame?

What percentage of the "people" who attended the hospital "outside core hours" died. Is that percentage significant, or was the Thawley tragedy a complete outlier?

Answer those and I'll be in a more informed position to try to answer your OP.
Institutions close ranks when they f*** up - it's how they operate whether they're private or public or whatever.

It's a natural enough reaction but the constant failure to challenge the closing of ranks in this country is scandalous.

This was a massive f*** up but the argument on these occasions always seems to be 'we get it right most of the time so the odd f*** up is regrettable' and that's about it. Compensation is then doled out more often than not by the taxpayer.

There's never any real acceptance of liability or real consequences for those who have f***ed up... more often than not just the vacuous mantra that 'lessons will be learned so this never happens again'... and off they go on their merry way until the next f*** up.
 
Last edited:

damus

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in May 2016, Malak Thawley went into Holles St for surgery on an ectopic pregnancy and due to a "cascade of negligence" died on the operating table. The coroner returned a verdict of medical misadventure noting the lack of blood products and staff shortages

Holles Street then decided to have a one man internal review with no results published. Simon Harris asked the clinical lead of the National Women and Infants’ Programme Dr Peter McKenna to examine the coroner’s report and that of the National Maternity Hospital and to give an opinion on the “appropriateness of the clinical reviews which have been undertaken to date”. Jack Chambers TD raised the issue on behalf of the family. He said there were contradictions between the internal hospital inquiry and facts outlined by the hospital and where serious adverse incidents occur in hospitals, they should not be allowed to investigate themselves. Mr Chambers said the family believed that “crucial, vital and extremely revealing new facts, incidents and events have only now come to light”. He said the family believe the internal hospital review was a “shambolic attempt to hide crucial facts and salvage reputations”.

After this, the minister order HIQA to undertake a s9 review of Holles street and this review was yesterday challenged in the High Court when Holles st sought a JR of the minister's decision stating, on an ex parte basis, that "The particular type of review currently directed by the Minister for Health would be carried out under Section 9.2 of the Health Act, a section to be used only when the minister believes there is a serious risk to patients.This conveys to our staff and our patients that the minister believes that emergency surgical practice in this Hospital outside “core hours” is unsafe." the hospital also argues that the manner the inquiry is to be carried out would “have a chilling effect” on the delivery of high risk and emergency care at the hospital.

It's arguable that having people dying in your hospital , having an internal unpublished review and then getting out the lawyers when the agency charged with investigating these matters is instructed to investigate you would have even more of a chilling effect.

https://www.irishtimes.com/news/crime-and-law/courts/high-court/damages-paid-after-death-of-malak-thawley-at-holles-street-1.3357391

https://www.rte.ie/news/health/2018/0129/936797-holles-street/
so is Holles st being reasonable or is it the classic case of putting the institution ahead of learning the lessons and protecting the patient?
The application for a judicial review is just another one of those accidents I suppose, along with what happened Mrs Thewles, what Rhonda said to her husband, inexperienced doctors who never performed that procedure alone before, no senior decision maker being on site, the patient not being made aware of any of this, notherwise to mention doctors doing relays down to the pub for buckets of Ice. Yep, Hollesley street has nothing to hide. The findings of that report would be a not so glowing part in the resume of the Master of the new national maternity hospital.
 

artfoley56

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I note that you refer to "having people dying in your hospital" - so how many people and over what time frame?

What percentage of the "people" who attended the hospital "outside core hours" died. Is that percentage significant, or was the Thawley tragedy a complete outlier?

Answer those and I'll be in a more informed position to try to answer your OP.
I don't have those stats

https://www.irishtimes.com/news/health/national-maternity-hospital-and-rotunda-stop-monthly-data-on-baby-deaths-1.2692587

featuring such doozies as "The three Dublin maternity hospitals initially omitted information on clinical incidents but added it after The Irish Times reported on their statements. This information has now been omitted again from the statements published by the NMH and the Rotunda."

"The publication of detailed information on the performance of maternity units was championed by Department of Health chief medical officer Dr Tony Holohan and stemmed from a recommendation in the Hiqa report into baby deaths at Portlaoise hospital. However, it ran up against resistance from the masters of the Dublin maternity hospitals."
 

ger12

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Ask the former Master Dr Boylan or his sister in law the current Master Dr Rhona Mahony.
 

artfoley56

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Ask the former Master Dr Boylan or his sister in law the current Master Dr Rhona Mahony.
omahony is Boylan's sister in law?
 

Emily Davison

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I note that you refer to "having people dying in your hospital" - so how many people and over what time frame?

What percentage of the "people" who attended the hospital "outside core hours" died. Is that percentage significant, or was the Thawley tragedy a complete outlier?

Answer those and I'll be in a more informed position to try to answer your OP.
And how do we get that information if Holles street won't even reveal the results of their own inhouse review. At the very least her husband/family should be entitled to that. It's totally disrespectful to him and to her memory not to do so.
 

Emily Davison

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The application for a judicial review is just another one of those accidents I suppose, along with what happened Mrs Thewles, what Rhonda said to her husband, inexperienced doctors who never performed that procedure alone before, no senior decision maker being on site, the patient not being made aware of any of this, notherwise to mention doctors doing relays down to the pub for buckets of Ice. Yep, Hollesley street has nothing to hide. The findings of that report would be a not so glowing part in the resume of the Master of the new national maternity hospital.
Indeed Damus you've been very vocal on this case on here and have made many posts on it. From which we learn a lot about what is going down in Irish hospitals that is all hidden away. The arrogance of Holles street is breathtaking. Hopefully this high handed court case yesterday will bring it into mainstream media and onto radio shows. So that grieving husband gets answers.
 

CookieMonster

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I note that you refer to "having people dying in your hospital" - so how many people and over what time frame?

What percentage of the "people" who attended the hospital "outside core hours" died. Is that percentage significant, or was the Thawley tragedy a complete outlier?

Answer those and I'll be in a more informed position to try to answer your OP.
The fact that the circumstances for it to happen once exist is enough to know what many before, and perhaps after, were at similar risk and that luck alone was all that prevented it from happening more.

There is a reason standards and procedures exist, to prevent the risk of something going wrong.
 

MsDaisyC

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I hope that when the 8th is deleted from our Constitution, modern, less invasive methods like Metothrexate injections will be used to end ectopic pregnancies, rather than resorting to surgery every time and miscarrying women will be helped along, rather than left for days.
 

ger12

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artfoley56

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Yep.

You'd think that we had just two doctors in Ireland dealing with pregnant women.
maybe less time on the media and more time on matters maternity & medical is called for
 

ger12

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maybe less time on the media and more time on matters maternity & medical is called for
Maybe it is.

Co-locating with Vincents should have happened years ago. If it had this woman may have lived.:-(
 

Cruimh

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Sounds like a ****-up followed by an attempted cover-up. Will the public be reassured if they think that cocks-up are being swept under the carpet? I'd suggest they would be more reassured if they knew that if and when things go wrong, as they always can, then investigation and action to try and address any problems will be honest, open and transparent.
 

Shiloh

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I'd guess the delay in moving to St Vincent's has less to do with ownership of the building and more to do with private consulting rights for Holles St consultants.
 

Analyzer

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Yet another institutional state debacle of incompetence, ineptitude and coverups.

None of this is in any way surprising.

I presume that PRAVDA-rte will tell us that this could have been prevented with "more resources".

How much did the HSE get from the working people paying taxes last year ?
 


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