The Urology Services Inquiry has released its report, finding systemic failures in leadership, governance, and oversight at the Southern Health and Social Care Trust that resulted in serious harm to patients.

The inquiry, chaired by Christine Smith KC, examined care provided under consultant urologist Aidan O’Brien. While finding he was a skilled surgeon who did not intend harm, the report states the Trust failed to recognise that he was a doctor in difficulty and did not manage him appropriately.

The report says issues with Mr O’Brien’s practice were known for years but never satisfactorily addressed. Warning signs were missed and opportunities to act were not taken soon enough.

However, the inquiry emphasises that the failings went beyond one clinician. Weak governance, poor oversight, ineffective escalation, and underdeveloped leadership created conditions where patient safety was compromised. The Trust Board is criticised for not understanding or discharging its responsibilities, and for insufficient challenge and critical oversight.

The findings are based on patient and family experiences, including delays in diagnosis and treatment, including cancer care, and poor communication. Christine Smith KC stated that the inquiry’s task was to understand how harm occurred and why it was not addressed, concluding the deeper causes were systemic.

The Patient and Client Council welcomed the report. Chief Executive Meadhbha Monaghan expressed support for recommendations to strengthen patient involvement and communication, noting the need for a statutory right to independent advocacy. She emphasised that the response must be ambitious and swift, despite financial pressures.

Recommendations include declaring patient safety as the primary purpose of healthcare, creating a comprehensive leadership development programme, and sustained investment in data and information. The report calls for involving patients more meaningfully to drive learning and improvement.

The report is available on the inquiry’s website from 2:30pm on Wednesday 24th June.