"This should not have happened."
A Coombe Hospital consultant took doses of the Covid-19 vaccine home with them and gave it two family members, an independent review has found.
The review into the hospital's vaccine programme was ordered after it became known
family members of some of its staff received leftover Covid-19 vaccines on Friday, 8 January of this year.
Following the review, the Coombe's board concluded that the guidelines set out in the Template Vaccination Plan with regards to the priority list for vaccination were followed at all times, aside from the 16 doses administered to the families on 8 January.
A statement from the hospital reads: "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 eight 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 off-site.
The review reveals that an unnamed doctor "took the remaining vaccine home with them and administered it to two family members".
No vaccine was wasted, though the review identified alternative options that may have been available in respect of other recipients.
The hospital board found that decision-making, especially on the night of 8 January, was impacted by a range of factors.
These included:
- evolving guidance regarding the use of leftover vaccines and the number of vaccines which could be used per vial,
- nothing contained in the guidelines on the preparation of a standby list,
- the absence, at that time, of a centralised IT software solution,
- peaks and troughs in vaccine attendance creating less certainty about how many vials of vaccine to open and dilute at any given time,
- a pressured environment, compounded by long hours, Covid related staff absences and the challenge of implementing the vaccine for the first time alongside normal functioning of the hospital.
The board statement reads: "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 off-site.
"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: “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.
"We are also concerned that in the case of one family, two vaccinations occurred off-site. 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."
The full report is available to read
here.
