Tallaght Hospital HIQA report: Nobody was accountable for patients on trolleys
NO ONE was accountable for patients who were left lying on trolleys in corridors for long periods in Tallaght Hospital, a watchdog found.
An investigation also revealed patients were at risk while the State failed to hold the hospital to account for the quality and safety of services it provided.
The Health Information and Quality Authority (HIQA) launched an inquiry into the emergency department in Tallaght last summer after a patient died on a trolley.
Tracey Cooper, Hiqa chief executive, said the investigation found a history of long-standing challenges in leadership, governance, performance and management at board and executive level of the hospital.
There was also a failure of the State to hold the hospital, which was in receipt of significant amounts of State funds, effectively to account for the quality and safety of services it provided.
"These challenges resulted in the persistent, and generally accepted, tolerance of patients lying on trolleys in corridors for long periods of time with a lack of clarity as to who was accountable for patients," she said.
"This puts patients at risk, is not acceptable and should not be tolerated in any hospital in Ireland."
HIQA launched its first investigation into safety standards at a hospital emergency department amid concerns over care provided to patients and "a patient safety incident".
The A&E department regularly had a high number of patients on trolleys waiting for admission to wards.
A coroner warned that Tallaght Hospital sounded like a "very dangerous" place after a 65-year-old man died in a "virtual ward" - a name given to corridors and alcoves where patients are left while awaiting a bed in a ward.
During the investigation, Hiqa analysed all hospitals providing emergency department services nationally over a 24-hour hour period in August 2011.
This identified some significant concerns in relation to the waiting time for patients in some hospitals and the quality of the data and the amount of absent information with which to manage the performance of an emergency department.
The investigation also found the board did not have adequate arrangements in place to direct and govern the hospital, nor did it function in a sufficiently effective way to assure itself that the hospital was providing safe care to patients - including patients receiving care in the Emergency Department
Hiqa made 76 recommendations to improve standards in Tallaght and other hospitals nationally, as well as the changes to improve the accountability of the health system.
In 2010, Tallaght was at the centre of a scandal involving unreported x-rays and unprocessed referral letters.
Despite assurances that governance and administration at the hospital would be streamlined, nine months later the publication of the Hayes report on the scandal found the hospital has not yet fully implemented its recommendation to restructure the board to a smaller size.