CHI chair resigns as review finds use of springs in child spinal surgeries was ‘wrong’ (2025)

He has been chair of the board since it was established in 2019.

“Following discussions over recent weeks with the Department for Health, I now wish to step down and provide for an orderly transition to a new chair to allow for renewed enthusiasm and passion to guide this great organisation,” he said.

The damning Hiqa report found the use of metal springs during spinal surgery on children in CHI at Temple Street Hospital was “wrong”. It found that non-CE-marked springs were implanted into three children between 2020 and 2022.

It also revealed an “onerous and unrealistic” workload facing managers in all hospitals under CHI following changes as part of the move to the new children’s hospital.

The review was commissioned in 2023 after it emerged one spinal surgeon had used non-medical devices in children being treated for scoliosis.

HSE chief executive Bernard Gloster has demanded an early meeting with the board and executive of CHI.

Hiqa made nine recommendations for CHI, nine for the HSE, and one for all healthcare providers, including private hospitals.

The report found: “… the use of the springs formed part of a well-intentioned but ill-considered effort to provide an alternative approach to surgical treatment, involving a single operation, for a number of children with life-limiting conditions at CHI at Temple Street who had otherwise been facing multiple operations, each with its associated risks."

It concluded: “Use of the non-CE-marked springs as surgical implants was wrong.”

It was critical of information shared with parents before the surgeries, describing this as “wholly inadequate”.

It also said: “… while CHI was operating within the national policy for consent, in these cases, consent for these surgeries was not fully informed.” They recommended a review of CHI’s “overall approach to communication with children and families, particularly when things go wrong”.

It refers to the surgeon only as Surgeon A. Professor Conor Green is understood to have been on leave since 2023.

He described the use of the springs as “bespoke and experimental” to Hiqa.

He attended a conference in 2018 where a Dutch research team discussed the use of implantable spring-distraction systems for scoliosis. They used medical-grade titanium springs.

“The research team from The Netherlands told Hiqa that they were not contacted by Surgeon A at any time to discuss their research,” the report said.

Hiqa also found the surgeon did not contact the hospital’s Ethics and Research Committee.

The springs were not ordered through normal CHI processes, and they highlighted “key failures” in procurement systems. This led to a lack of clarity over the intended use of the springs.

Hiqa found “no formal structures and processes in place to support the surgical multidisciplinary team” at the hospital.

It highlighted “failures in the clinical governance of surgical safety” in orthopaedics.

Hiqa also identified “long-standing issues with communications and team dynamics” in the orthopaedic service.

External advice had been sought as far back as 2019 to address “behavioural and cultural issues”, they found.

Overall, CHI has faced “sustained challenges in providing timely access to paediatric spinal surgical services for many years, with long waiting lists for children,” Hiqa warned.

They raised questions about new governance structures for all CHI hospitals since 2021 as part of the move to the under-construction new hospital.

This said this is “overly complex and placed an onerous and unrealistic workload expectation on the clinical directors and senior managers”.

They said this created challenges for “clear lines of reporting and oversight of operations on a day-to-day basis at each of the hospital sites”.

Recommendations for the HSE

Among recommendations for the HSE is to focus on planning for organisational change and “careful evaluation” during transitions.

The HSE should also “review the effectiveness of the clinical directorate model, with a focus on the role of the clinical director” They thanked CHI staff and management, with special thanks to the families of children affected, for sharing their experiences and “valuable insight”.

Health Minister Jennifer Carroll MacNeill said: "I want to begin by apologising to the three young children and their families. What happened was wrong, should not have happened and should not have been allowed to happen. These children were not protected from the risk of harm, as they should have been."

She said she had met with both the chief executive and chairperson of Children’s Health Ireland.

"We discussed the report, its findings, and the recommendations," she said. "I made very clear to them my deep disquiet at what happened here and my clear expectations in terms of reform and change to ensure it does not happen again."

CEO of CHI Lucy Nugent apologised to the families affected.

“We are deeply sorry that these children, young people and families did not get the care they deserved. This is unacceptable,” she said on Tuesday.

Children’s Health Ireland sincerely regrets and apologises for the risks that were posed to three patients through the use of non-CE-marked spring implants in their spinal surgeries.

"We do not underestimate the impact that this has had and is having on the families affected, and the distress that it has caused to all patients and families in the spinal service.”

CHI has been working on changes and measures to improve care for the children and families affected.

She added that all recommendations will be implemented.

“Issues of poor performance and non-compliance with policies are being addressed with the staff involved, in line with relevant hospital policies. I want to assure families of my commitment to ensuring that something like this never happens again in our organisation,” she said.

Speaking to RTÉ, Ms Carroll MacNeill declined to say whether she has confidence in the board of CHI.

Asked whether she has confidence, she pointed instead to the appointment of a new CEO earlier this year.

“For me now what I need to do is reflect on the board and reflect on the next chairperson and the steps that are taken towards that, and that is something I will do,” she said in response to a question as to whether more resignations are needed.

She also declined to say whether she has doubts about the current management’s ability to run the new children’s hospital. She described the spinal surgeon at the heart of the controversy as “a rogue surgeon” and said also Hiqa found he acted with good intentions.

The minister also said a separate external review commissioned by the HSE and led by a UK consultant is now at draft report stage. The final report will be shared with her, she confirmed.

The report has been described as "devastating" and "horrific" for children and their parents, by members of the opposition.

Sinn Féin health spokesperson David Cullinane said: "It's one of the most devastating reports that I've seen in a long, long time. There's one line in the report which I think is really devastating for children's healthcare where it says that children are not prevented from harm, are not protected from harm. That's a really devastating critique."

He said the report's finding has "real implications" for CHI as well as the Government, but he warned that a statutory inquiry could drag on for years if that route is taken.

Labour TD Marie Sherlock said the report reveals an "utterly dysfunctional set of processes" in the National Children's Hospital.

She said ahead of the move to the new Children's Hospital, answers must be given as to what has been done to resolve the "deadly serious issues" around the "lack of oversight" and poor culture" within the hospital.

"The second question key question is, is CHI now capable of managing both the transition to the new hospital building in spring of next year, while also implementing those very wide-ranging set of recommendations that Hiqa has issued?"

The review can be read on the Hiqa website.