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Neonatal project allowed ‘to slip into abeyance . . . not by an active decision but through neglect and apathy’

Dr Ann Hickey this month told management of Children’s Health Ireland she could no longer continue as neonatology lead due to inaction on outdated systems of care

Concerns about potentially unsafe care of newborn babies who undergo surgery at Dublin’s children’s hospitals have been flagged on successive occasions recently by doctors to the management of Children’s Health Ireland (CHI).

Consultant Dr Ann Hickey told the CHI earlier this month that she could no longer continue as neonatology lead, due to inaction on outdated systems of care for these very vulnerable babies.

In sharing her decision with colleagues – in a letter seen by The Irish Times – Dr Hickey said that the “absolute failure” of the CHI executive to support the development of a neonatal intensive care unit (NICU) and “more recently to ensure that we are safely staffed to provide care to non-ICU neonates [infants aged under 28 days]”, had left her with no choice but to leave the role. She blamed “neglect and apathy” on the part of the CHI executive for stalling over the setting up of a NICU in one of the existing children’s hospitals, in advance of the move to the new national children’s hospital.

It has also emerged that two months ago, a group of paediatric intensive care doctors in CHI@Temple Street had warned CHI management about “major vulnerabilities” in the critical care arrangements for newborns admitted there for treatment. As a result, “we are failing to meet the specific needs” of these infants, they wrote in a letter, also seen by The Irish Times.

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“We believe that the current model of care has passed a threshold of foreseeability for adverse outcome,” the six doctors said last February in a letter addressed to Ms Paula Kelly and Dr Allan Goldman, CHI’s clinical director and chief medical officer respectively. With a high morbidity and mortality rate to be expected among these very vulnerable babies, they pointed out, “an enquiry into an adverse outcome may identify deficiencies in the process of care”.

Among their five recommendations back in February for urgent action was a call to the CHI leadership to work with neonatology lead Dr Hickey

Each of Dublin’s three maternity hospitals has a NICU for premature and very ill newborns, managed by neonatology consultants, as does Cork University Hospital. But if babies have to be transferred to one of the dedicated children’s hospitals for surgery or specialist review within days, or even hours, of their birth; in those cases there is no equivalent specialised life support there.

Staffing and facilities in a paediatric ICU (PICU) are not designed for up-to-date, specialist care of low-birth weight and preterm infants and a level 4 surgical NICU is planned for the new national children’s hospital in Dublin.

However, as this hospital has been delayed for many years, it was recognised an interim solution needed to be set up in either Crumlin or Temple Street hospitals. This would also ensure that there was an established service, with the necessary specialised neonatology staff, ready to transfer to the new hospital built on the site of St James’s Hospital in Dublin 8.

PICU staff in Temple Street outlined to CHI eight key issues behind their safety concerns about the continued use in the hospital of an outdated system of care for premature and extremely low birth weight (ELBW) infants. These include lack of neonatal specialist training among PICU staff and a shortage of CHI consultant neonatologists. As a result, there is “phone only” cover at times at night and that is with consultant neonatologists working in the Rotunda Hospital.

The doctors also expressed concern about the use of equipment intended for larger babies and children. “Specifically, our ventilators are not designed and/or optimised for the care of ELBW infants.”

With older children coming into the PICU, often as emergency admissions, there is a “significant risk of cross infection” in the unit. Small infants are particularly vulnerable to acquiring healthcare-associated infections.

They also said that Temple Street’s PICU is a temporary structure, which had passed its planned operational lifespan. “We are concerned that the age of the structure might lead to fungal contamination of vulnerable patients.”

Among their five recommendations back in February for urgent action was a call to the CHI leadership to work with neonatology lead Dr Hickey, “to allow her and her team to successfully open a level 4 surgical NICU in advance of the NCH [national children’s hospital]”.

But now she has stepped down, telling colleagues that this neonatal project has been allowed “to slip into abeyance, like most other aspects of the service, not by an active decision but through neglect and apathy”.

A colleague says Dr Hickey’s decision came as a ‘massive shock’ to the neonatology community because they had huge faith in her

She said while she understood the CHI executive were struggling with multiple issues, “the approach to what I see as an essential neonatal development for Ireland, which was a priority for the organisation when I started in post, is not acceptable”.

Dr Hickey was recruited by the CHI in 2020 after working for 12 years in London’s prestigious King’s College Hospital.

The level 4 NICU “will happen because it has to”, she added. “The path is just not clear at present.”

It is believed that a failure both to agree on the location of an interim NICU and to secure funding for recruitment of the necessary medical and nursing staff became obstacles to advancement of plans, after two years of progress. Ireland is one of the few developed countries in the world not to have a NICU in a children’s hospital where newborn babies are undergoing surgery, or receiving care for, say, neurological or renal problems.

A colleague says Dr Hickey’s decision came as a “massive shock” to the neonatology community because they had huge faith in her. In addition to the concerns about the current system of care for these very vulnerable babies, neonatology professionals have said that without established NICU within CHI to transfer to the new national children’s hospital, it may be several years before a neonatal intensive care service could be operational there.

The Model of Care for Neonatal Services in Ireland, published at the end of 2015, outlined the plans for the NICU in the new children’s hospital and how intensive care of newborns would be managed by neonatologists, rather than PICU consultants as is the current practice. This guidance, produced by the National Clinical Programme for Neonatology and Paediatrics, stressed that it was “imperative” that the appointments of neonatology consultants and advanced neonatal nurse practitioners be implemented in the “run up, four-year period before the new children’s hospital opens”.

In a written response to The Irish Times on some of the issues raised by the doctors, Children’s Health Ireland said it currently provides paediatric intensive care services at both Crumlin and Temple Street hospitals and was committed to delivering the highest standard of clinical care possible.

“We cannot comment on the status or remarks of individual employees,” it continued. “However, we remain fully committed to the opening of a neonatal ICU at the new children’s hospital and planning continues to support this development. As with other areas of the health service, CHI is working through recruitment and staffing challenges to ensure the successful opening and operation of the unit.

“That planning will continue,” it added, “until the unit opens at the new hospital – a child-centred, world-class facility that will support innovation and excellence in paediatric healthcare, and create an environment that is supportive of children, young people, their families, and the hospital’s staff”.

There was no mention of a neonatal ICU service being established in either Crumlin or Temple Street in advance of the move to the new hospital. The new 380-bed hospital still has no opening date, but it is not expected to be before the summer of 2025 at the earliest. The final cost of the development was put at €2.2 billion by the Government last February.

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