It has not been a good couple of months for Children's Health Ireland.
First came the HIQA report into the spinal surgery controversy and governance questions over the use of unapproved springs in procedures for children with scoliosis.
The hips surgery scandal, which led to 1,800 families being told invasive hip surgeries their children received may not have been necessary, soon followed.
In between the high-profile incidents, CHI faced yet more questions after the National Paediatric Hospital Development Board said the new children's hospital is facing its 15th delay, will cost even more than already planned and will not begin treating patients for at least another year.
And, if all that wasn't enough, last month four CHI voluntary board members resigned from roles amid Department of Health calls for improved governance, following on from then-CHI board chair Dr Jim Browne's decision to step down in April in the wake of the spinal surgery revelations.
The multiple, unrelated difficulties mean CHI officials are far from inexperienced when it comes to responding to controversial situations.
But recent revelations around an unpublished 2022 report into issues at a CHI facility - including claims by some staff interviewed by the report team of a "toxic" working culture, "dysfunctional relationships" which could be impacting patient care and a fresh public finances controversy - appear to be more deep-rooted than what has come before.
On Wednesday evening, the cabinet sub-committee on health, attended by Taoiseach Micheál Martin, Tánaiste Simon Harris, Minister for Health Jennifer Carroll MacNeill and others, was told that the HSE will refer the report on the latest controversy to An Garda Síochana in the coming days.
The following morning, the HSE itself confirmed that it is also planning to refer the case to the Medical Council of Ireland.
The developments have led to significant interest in the report, with the Taoiseach, Minister MacNeill and a plethora of opposition TDs saying in their view the report should be published, either in full or partial form.
CHI has for now said that due to legal reasons this is not possible, confirming in a statement evening that in light of those political calls it is seeking further legal advice on whether, and when, it can publish the document.
But, despite these concerns, there are details of the report which are at this stage public.
What is the report about?
The 112-page report, which has been seen by RTÉ News, was carried out and completed in 2021 and 2022 due to a number of alleged issues at a CHI facility.
These issues related to interpersonal difficulties between staff, a dysfunctional working environment and claims of a toxic culture.
But the report's author went further, detailing concerns over how waiting lists were managed and whether consultants were working together in the best way possible to ensure patients with sometimes significant conditions were seen as soon as possible.
These concerns led to claims detailed in the report over one consultant, who the report said was seeing a number of patients during weekend work via the National Treatment Purchase Fund system and outside of their contracted hours, during a period in which the consultant was unable to work all of their public contract hours.
That final point, the report said, ultimately resulted in this consultant receiving €35,800 for this work via the NTPF - a service designed to tackle public waiting lists by funding hospitals for appointments to take place either using extra public capacity or using private hospitals - leading to yet more questions about what happened.
All details of the concerns, including the name of the hospital, the specific service involved at the hospital, the consultants and the type of procedures involved, are outlined in the report.
However, they cannot currently be published for legal reasons, and while politicians have said they want the information to be made public, this is not at this time their decision as legally the report is the property of CHI rather than the HSE or Department of Health.
This means that it is CHI's decision on whether, and when, the report can be published.
Interpersonal difficulties
While the media and political spotlight of recent days has been on the financial issues outlined in the report, more than half of the document itself focusses firstly on the interpersonal difficulties in the service at the centre of the claims.
These issues provide an important context for what was taking place in the service at that time.
When the report was completed in 2022 it concluded that CHI had "a broken culture created by dysfunctional relationships and challenging behaviours" which are "negatively impacting service delivery, department dynamics and staff experience".
The report said the issues carried "the potential to put patients at risk", and that "numerous [individuals working in the wider service] expressed concern for the emotional and physical well-being of colleagues".
These issues were identified by the report's author through 49 "one-to-one meetings" conducted over a four-month period "with CHI staff and those who have experience of working within or alongside the service", in addition to "hundreds of pages of supporting documentation".
As soon as page eight, the report stated that "consistently throughout this examination it was found that participant experiences reflected a culture in which challenging behaviours appear to be the norm".
It said that the service being examined received "a risk score of 20 out of a possible 25", meaning the situation was officially classed as "intolerable", and said at least some of this was due to the idea of consultants generally being considered the "lone captain of their ship" or "the heroic leader" who is above reproach.
It separately said the experience of trainee medics at the service was difficult, with the Specialist Advisory Committee which oversees trainee placements in Ireland and Britain saying at the time that "there should not be an intake of any new trainees into the programme in 2022".
The report continued to say that "feedback from trainees both past and present is resolute", with "observations from many participants all describing an environment and working life that is adversely impacted by the 'negative' and 'toxic' culture that exists".
It said that "across multiple participants [in the one-to-one report meetings] there was one consultant identified consistently as creating a psychologically unsafe environment not conducive to learning", compared to other consultants who were described as being "what a trainer should be".
It cited an example of "the exceptionally high rate of attrition among clinical nurse specialists" in the service.
And underlining the scale of the situation, it said that "the lack of consistent and appropriate management of negative behaviours which appears to have gone unchallenged for a significant period of time has led to a toxic and siloed culture where many staff feel unsupported and have disengaged from the wider organisation".
Financial concerns
At the same time as these interpersonal difficulties, the report stated that there were also concerns over the use of the NTPF system.
These concerns included why one consultant was referring patients to themselves, and seeing the patients via the NTPF system while at the same time being unable to complete their publicly contracted hours for health reasons.
Page 72 of the report said that between December 2020 and March 2021 five NTPF clinics were held over five weekends, with the consultant referred to above seeing an average of one new patient every ten minutes.
For each consultation, the consultant was paid €200 per patient, with the report saying that "after receiving 179 patients the total funding required from NTPF to pay the consultant was €35,800".
The report continued that "when the NTPF clinics carried out by [the consultant] are compared to that consultant's regular clinic there is a significant difference in the through-put of patients", before saying "it must be highlighted that this consultant is not currently fulfilling their public contract commitments due to health issues".
Read more: 64 out of 2,700 approved CHI procedures progressed to date, NTPF review finds
Posing a question to CHI, the report's author stated:
"It needs to be explored how one consultant can undertake a series of NTPF clinics over numerous [weekends] and during these clinics see a much greater number of patients than they are able to see in their routine public clinics, a substantial undertaking of additional work, yet is unfit for any on-call duties for [a period of time outlined in the report]."
In its conclusions on this stage of the document, the report stated: "There are significant concerns relating to the prudent and beneficial management of NTPF funding and lack of oversight of access initiatives, which are ultimately not in keeping with the Memorandum of Understanding between CHI and the NTPF."
It continued: "Any and all consultants who have been identified as directing, supporting or facilitating the inequitable and unfair distribution and management of referrals for whatever reason, should be held to account and consideration given as to whether the matter should be referred to the Irish Medical Council and/or any other relevant body or organisation.
"CHI, and indeed the HSE, cannot and will not stand over behaviour or practice which undermines the integrity of public organisations...The scenarios outlined in this paper go against this and the CHI values of integrity and child-centredness."
Waiting list management
In addition to the interpersonal difficulties and the NTPF financial concerns, on a number of occasions the report also highlighted concerns over the management of the child patient waiting lists involved.
While not saying the two narratives were intrinsically linked in all scenarios, it said what it described as a "dysfunctional" working environment was potentially playing a role in a lack of sharing of patient appointments to ensure individual children were seen as soon as possible.
In its overall conclusions, the report stated that "the lack of clarity, consistency, and transparency regarding management of referrals and waiting list oversight is negatively impacting inter-personal relationships, operational efficacy, and significantly is not in the best interest of the child".
Specifically in relation to the NTPF appointments with one consultant, the report said the use of the NTPF system to see patients was in its view "questionable", saying it is "a significant cost to the exchequer which potentially could have been avoided" given evidence "95% [of the patients] could have been safely and effectively managed" in a different way.
It said the information provided "would strongly suggest that patients are being placed onto waiting lists despite an existing alternative option being available for quicker treatment and care".
And in a section related to child patients with serious conditions, the details of which cannot currently be published as they may identify individuals involved, it said: "Placing these patients on a specific consultant's inpatient waiting list when it was known there were alternative options which would have ensured these patients could have been [seen] sooner appears not to be in the best interest of the child."
Potential impact on patients
It should not be forgotten that the children and families who were on these waiting lists are the reason why the still unpublished CHI report is gaining such attention, with the case not simply being about a bureaucratic, financial or political controversy in the making.
At its core are children who are patients and who along with their families were at the time of the report waiting for vital care for significant and sometimes serious conditions, which at this point in time cannot be disclosed for legal reasons.
The report makes this clear on several occasions, saying in the second sentence of its final conclusions that the issues outlined were in the report author's view "negatively impacting service delivery, department dynamics and staff experience and have the potential to put patients at risk".
The report does, however, conclude on something of a positive note for CHI, saying that if concerns over the issues were genuinely taken on board "there is a real and tangible opportunity now to shape a new and progressive CHI ensuring we fully realise our vision of being a child-centred, compassionate, progressive organisation acting with respect, excellence and integrity".
That conclusion was, of course, when the still unpublished report was completed three years ago.
Whether the coming days and weeks bring that "real and tangible opportunity" for CHI or not is a dilemma now facing officials as the group faces the fallout from another controversy under its watch.
