A COOMBE CONSULTANT took home leftover vaccine doses to deliver them to two family members, a review into vaccinations at the hospital has found.
The Board of the Coombe Hospital has discussed the independent review into the vaccine programme which was ordered after it emerged family members of some hospital staff received leftover Covid-19 vaccines earlier this year.
The board said guidelines set out in the plan for the priority list for vaccination was “followed at all times”, aside from the the 16 doses given to families of some hospital staff on 8 January.
“These doses were administered after Hospital personnel formed the view that no other frontline staff were immediately available for vaccination,” the board said in a statement.
“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 doses were administered across eight families “who otherwise would not have been eligible to receive the vaccinations that evening”.
Nine of the 16 recipients were over 70 and the other seven were of varying age.
Two of the vaccinations in one family occurred offsite.
The review said that a consultant “took the remaining vaccine home with them and administered it to two family members”.
The review identified other, alternative options “that may have been available in respect of other recipients”, the Board said.
The Board statement said that consideration of options and decision making were impacted by a number of factors including developing evidence about the use of leftover vaccines and the number of doses per vial, the “absence at the time of a centralised IT software solution” and “peaks and troughs in vaccine attendance” creating less certainty around how many vials to open.
“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,” the Board said.
The Chair of The Coombe Women & Infants University Hospital, Mary Donovan, said 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,” she said in a statement.
“The Board takes what occurred extremely seriously and has started a process to address the implications.”
Donovan said key actions and measures are being implemented to ensure this doesn’t happen again.
She said that “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.”
The independent review was carried out by Brian Kennedy SC. He found that a complete vaccination programme was conceived, put in place and carried out within six days of agreeing to offer the programme at the hospital,.
The review said that a difficult during the early vaccinations “was the absence of a functioning software system to manage the vaccination process”.
“The Hospital does not have an existing human resources IT system which could assist and a specific software package for the administration of the vaccine, Covax, which the HSE had developed in conjunction with IBM and Salesforce, was not ready when the vaccinations took place,” the report said.
It also found that one vaccine vial had to be discarded “due to excess pressure” in the vial when the sodium chloride solution was added. This led to “the needle popping out and the loss of an unknown volume of the solution”.
Vaccines were scheduled to arrive on the morning of Friday, 8 January. Hospital staff were prepared to work on Saturday, but it was aimed to deliver all doses on Friday if possible.
At this time, the hospital had committed to vaccinating 25 local GPs connected with the hospital and there was a request from the DMHG to make further vaccines available to local GPs and community healthcare staff.
Employees were notified when 95 vials arrived at the hospital that morning. Hospital staff and GPs were vaccinated that evening.
“It appears that some other frontline healthcare workers, who were not contacted
directly by CHO7, may have arrived at the Hospital, having been informed by other
frontline healthcare workers, and were vaccinated,” the report said.
When it became clear some vaccines would be leftover, consultants went to different hospital floors to ensure “as many eligible staff as possible” were vaccinated and other wards were called to identify possible additional staff.
The open vaccine vials had to be used by 2.30am at the latest. There was no standby list in place and no guidance which suggested having this list in place at that time.
“While Consultant C did not state it to the group at the time, Consultant C stated in
an interview that they gave thought at the time to the possibility of seeking to get
candidates from the nearest Garda Station or Fire Station. Consultant C indicated
that they were concerned about consent procedures that would apply, as well as a
lack of knowledge of medical history. They also had a concern as to whether
medical legal cover would be available. That being so, Consultant C did not raise
the possibility with the group,” the review found.
“At some stage in the conversation, the possibility of using the remnant vaccines to
vaccinate family members was raised. It was not possible to establish who first
raised this possibility from interviews with those present but it may be that the first
reference was by one individual to the fact that another individual had an elderly
family member or members living relatively nearby.
“While it was not possible to get clarity as to precisely what transpired next, it
appears that the subsequent consideration of the issue was relatively brief and that
a consensus was reached that the remnant vaccines would be made available to
family members of those present.”
The review said that there was no suggestion that there had been any disagreement about this course of action.
It added that an online training video watched by the consultant who brought the vaccines home said that diluted vaccines “should not be transported for administration in another location”.
“When asked about this, Consultant B stated that while they had watched the relevant on-line video, they did not recall the reference to the transportability of the vaccine and did not give it any consideration on Friday evening.
“Consultant B lived relatively close to the Hospital and understood that the vaccine would still be effective if it were transported by car over a relatively short distance.”
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