A statement from The Board of the Coombe Women & Infants University Hospital
Statement from The Board of The Coombe Women & Infants University Hospital
The Board of The Coombe Women & Infants University Hospital [‘the Coombe’, or ‘the Hospital’] has met to discuss the Independent Review, carried out by Brian Kennedy SC, into the vaccine programme undertaken at the Hospital.
The scope was to carry out a factual review into the commissioning, planning and execution of the vaccine programme at the Coombe in January, 2021. The Review found that within a six day period, a complete vaccination programme was conceived, put in place and carried out which resulted in the successful administration of the first doses of the vaccine to almost 1100 people, with a small number of vaccines being administered the following Monday.
Having considered the Review the Board has concluded that:
Guidelines set out in the Template Vaccination Plan in respect of the priority list for vaccination, were followed at all times, save for 16 doses administered to the families of some Hospital staff on the night of Friday 8th January. These doses were administered after Hospital personnel formed the view that no other frontline staff were immediately available for vaccination. The Clinical Guidance then available stated that leftover vaccines were to be discarded, although the subsequent Sequencing Guidance, which post-dated the first round of vaccinations at the Hospital, stated that no doses were to be wasted.
The 16 vaccinations were administered across 8 families who otherwise would not have been eligible to receive the vaccinations that evening. Of the 16 recipients, nine were over 70 and the remaining seven were of varying age. In the case of one family, two vaccinations occurred offsite.
No vaccine was wasted.
The Review identified other, alternative options that may have been available in respect of other recipients, and the difficulties which may have applied to these groups.
Consideration of options and decision making, most especially on the night of Friday, 8th January, was impacted by a range of factors including:
o evolving guidance regarding the use of leftover vaccines and the number of vaccines which could be used per vial
o there was nothing contained in the guidelines on the preparation of a standby list
o the absence at that time, of a centralised IT software solution, required manual management of the process (to include potential recipients) until the HSE’s Covax software system subsequently became operational
o peaks and troughs in vaccine attendance creating less certainty about how many vials of vaccine to open and dilute at any given time
o a pressured environment, compounded by long hours, Covid related staff absences and the challenge of implementing this vaccine for the first time alongside normal functioning of the Hospital
Notwithstanding mitigating factors, the Board accepts that mistakes were made, not least in the decision to vaccinate family members and, in one case, in the administration of two vaccines offsite. Lessons must and will be learnt to ensure that similar issues cannot recur.
Commenting, Chair of The Coombe Women & Infants University Hospital, Mary Donovan, said:
“The vaccination programme managed by the Hospital saw over 1,100 vaccine doses administered to frontline staff, GPs and local community health workers. It is clear from the facts established by the Review that the programme was rolled out at the very early stages of the vaccine programme in quite unique circumstances. It is also clear from the Review that those administering the vaccine did maximise the number of doses from the vials and that no vaccines were wasted. The Review also found that on the evening of Friday 8th January the team at the Hospital made efforts to identify other front line staff.
Despite the mitigating factors, and the overall success of the vaccine programme, the Board is disappointed that 16 family members were vaccinated with leftover vaccines. This should not have happened. We are also concerned that in the case of one family, two vaccinations occurred offsite. Again, this should not have happened.
The Board takes what occurred extremely seriously and has started a process to address the implications. In addition, key actions and measures are being implemented to ensure such an incident could not occur again and Hospital guidelines and protocols will be enhanced with a particular focus on embedding our strong values as a community-based voluntary Hospital.
In the interests of transparency and accountability, the report of the Independent Review has been published to our website and a copy of the report has also been shared with the Minister for Health, the HSE and the Medical Council.”
The Board will not be commenting further.
Ends
The Independent Review and Appendices are available below.