For Vicky’s sake, we must all ensure that the HSE’s horrifying ‘culture of cover-up’ is finally rooted out

AND so another victim is added to the list of patients scandalously and tragically failed by our health service. Vicky Phelan now joins Kay Dunne, Brigid McCole, Susie Long and Róisín Molloy as one whose name alone is enough to invoke a shameful episode that exposed a culture of cover-up, neglect, inequality or incompetence within the organisation we trust with our lives.

Each name recalls an outbreak of national hand-wringing and soul-searching. Each one prompted public outcry, and rocked our faith in the health service that we spend so much to maintain. Each one brought political and clinical mea culpas, explanations, apologies, excuses. They led to inquiries, tribunals, Medical Council hearings, Dáil questions.

But none of them led to change. None of them led to a meaningful review of the culture of denial, obfuscation, buck-passing and blame-shirking that they all, in their different ways, exemplified.

Denial

The irony is that the first of these names, one most of us have long forgotten, should also have been the last. If lessons were ever to be learned by our health service, they would have been learned from the first big medical negligence case, the saga of Baby William Dunne versus the National Maternity Hospital, which gripped this country in the late 1980s.

Baby William was a twin, whose brother Martin was stillborn and who was himself born with catastrophic brain damage in 1982. A few years ago his mother Kay, who became a national heroine through her battle for her broken boy, told a conference on cerebral palsy that William is now in his 30s, forced to use a wheelchair, spoon-fed and mute, and will require round-the-clock care all of his life.

Contrary to normal practice at the time, it emerged in the course of the Dunnes’ long-running legal battle, only one of the foetal heartbeats was monitored during Kay’s labour and so the evidence of William’s pre-natal distress was missed. But when the Dunnes sought answers from Holles Street they were stonewalled.

They then went to two successive health ministers who also assured them that the medics had done nothing wrong – it was not common practice, the ministers were told, to monitor both twins’ hearts.

As a last resort, the Dunnes went to law, where the hospital’s jaw-dropping disregard for truth and transparency emerged. Ten women came forward to say that, during their twin pregnancies, both babies were monitored – the ministers had been misled as part of the hospital’s efforts to deny the error at all costs. The case ended up in the Supreme Court and the Dunnes eventually reached a financial settlement with Holles Street.

But if only they’d been given the answers they sought, if only they’d been treated with dignity and compassion, Kay Dunne told that recent conference, they might never have taken their case at all. More than a quarter of a century on from their famous battle, Kay Dunne called on the health service to be honest with families and patients, and to admit their failings when it becomes obvious that a mistake has been made, rather than lawyering up and dragging the patients through the courts to suffer as they did.

The sight of little William being wheeled from court, his life permanently blighted by the circumstances of his birth, horrified the nation and was almost certainly a factor in the hospital’s decision to settle with the Dunnes. But how many William Dunnes have we seen since then?

Outrage

There have been so many that we’ve long since ceased to be stricken with the compassion and outrage that attended the Dunne case all those years ago.

And how many times, in the decades since, have we heard of hospital coverups, amended notes, altered records, and stonewalled patients left with no option but to sue? In the past week alone, two instances of alleged cover-ups and misinformation were reported with scarcely a ripple of disquiet. On Thursday, the HSE apologised to the parents of baby Ciara Loughlin, who died at birth in the Midland Regional Hospital. Like the Dunnes, the Loughlins just wanted answers but did not accept the hospital’s insistence that Ciara’s 2007 death was unavoidable.

Before the case settled, the HSE apologised for the fact that the hospital records had been altered: this was done, the plaintiffs’ lawyers said, to suggest that Mrs Loughlin had arrived at the hospital an hour later than she did… in order to claim that there had not been a delay in performing a caesarean section.

And in the same hospital in 2012, Róisín and Mark Molloy were told their baby was stillborn but later found he was born alive. Last week, the obstetrics registrar in charge of Mrs Molloy’s labour was found guilty of medical misconduct after he admitted altering his notes retrospectively. Again and again, the instinct to deny, obstruct, conceal the truth from bereaved or injured patients appears so prevalent coincidence doesn’t explain it.

Havoc

Look at the note circulated by CervicalCheck, and revealed by Vicky Phelan’s ordeal, to doctors treating patients whose misdiagnoses were revealed in that 2014 audit. It advised them to use their ‘judgment’ to decide whether telling women of the audit would ‘do more harm than good’. And where women previously given the all-clear had since died of the disease, clinicians should ‘simply ensure the result is recorded in the woman’s notes’ – don’t, in other words, do anything rash like telling her family what happened, don’t let on she might have been saved if the 2011 test had been correctly read.

A similar instinct to protect the institution at the expense of those it serves has caused havoc within the gardaí. And, like the gardaí, the HSE will shortly be appointing a new head, following Tony O’Brien’s imminent departure. For both organisations, their recent upheavals and personnel changes represent an opportunity for fundamental change if they can find the courage to grasp it.

A proper inquiry into Vicky Phelan’s case needs to identify the person who made the call to withhold details of that audit, and to hold them responsible. But a far wider reckoning of accountability, honesty and systemic attitudes must also follow within the HSE. Because we can no longer deny that these attitudes are endemic, and come right from the top. Mistakes happen in all walks of life. Not even the best of leadership will ever eliminate human error, but a new regime in the HSE could certainly eliminate the culture of cover-up.

The Government now needs to seize this opportunity to institute a new regime of transparency and candour.

And the HSE needs a boss who insists at all times on errors being immediately acknowledged and addressed.

Three decades of denying and hiding errors has not made them go away, so it is clearly time for a change of approach.

If that can happen, then the painful ordeal suffered by Vicky Phelan and her loved ones will not be in vain.