The HSE is no stranger to catastrophe but this latest omnishambles is truly horrifying. Our Lady's Children's Hospital in Crumlin has launched an investigation to determine how 18 families were incorrectly informed their children may have been contaminated by a colonoscope.
Think about that for a moment. Imagine that yours is one of the families affected.
Think about the worry of having a sick child undergoing tests and then the devastation wrought when the hospital calls to tell you that your child has been exposed to a dirty medical instrument.
Think about the torment and the sleepness nights those families suffered in the wake of getting that news.
Health Minister James Reilly, clearly a master of understatement, said there was a "communication issue" at Crumlin.
No, minister. This is not a communication issue. It represents staggering incompetence on the part of the hospital at every level.
Firstly, it transpired that the medical instrument used in invasive procedures on children was cracked.
Secondly, the hospital is now in the process of replacing the sterilisation equipment that is used for disinfecting scopes. Are we to assume that the disinfection procedure, with the old equipment, was at fault?
And, if so, how can we be sure that other contaminated medical equipment has not also been used?
Finally, how can we have any faith in an organisation which, when serious problems are discovered that impact patient safety, can't even manage to correctly identify the people who may be affected?
According to the HSE, the problem first became apparent on July 6, when two colonscopes – which are used in bowel examinations – failed hospital safety tests.
However, parents were not informed until July 10, because the hospital wanted to double check the identities of those who may have been exposed.
Despite all of this exacting scrupulousness, the wrong families were called and told that their children were at risk.
Now, there are seven other families out there who have been told that their children may have been infected. HSE Director General Tony O'Brien won plaudits for his matter-of-factness at an Oireachtas Health Committee yesterday when he said the incident was a "catastrophic failure" which "no amount of spin" could ameliorate.
Evidently, we have become so inured to obfuscation and stonewalling by HSE bureaucrats that we are now pleasantly surprised when someone actually tells it as it is.
Really, how could Mr O'Brien have called it anything other than catastrophic?
Crumlin Children's Hospital is now the second hospital in less than a week that has revealed it exposed its patients to infection from the use of contaminated medical instruments.
Last week, we learned that up to 20 patients at Beaumont Hospital may have been exposed to a fatal disease, CJD, with more than 1,400 people calling a helpline over the weekend to try to get information about the scare.
The reason that so many frantic people called the helpline is because the HSE was loathe to release information, refusing to even reveal the exact number of patients involved or if it had deigned to meet with them.
On that occasion, the chairman of the Irish Patients Association, Stephen McMahon, said there appeared to be an "information deficit" at the hospital.
So, "information deficits" and "communication issues" abound. But we are not talking about innocuous clerical errors. We are talking about people's lives and these blunders, which cause unimaginable alarm and stress to people, are not good enough.
It has been said that sunlight is the best disinfectant and, if the HSE wants to regain patient trust, it must be more forthcoming when mistakes occur.
All too often, systemic errors are blamed when, in reality, there are people implementing those systems who should be made culpable.
At the very least a comprehensive report into this latest fiasco should be published as soon as it is completed. And, if people are found to be responsible, heads should roll.