1. Good afternoon everyone and welcome to the launch of the Urology Services Inquiry Report. As you know I am Christine Smith KC, Chair of the Inquiry. I am here with Dr Sonia Swart the Inquiry Panel Member and co-author of the Report and the Inquiry’s assessor, Mr Damian Hanbury.
2. I want to begin by thanking them for the support, hard work and dedication they have shown to the Inquiry and the support they have provided to me personally. Their expertise in the fields of urology and governance has been of immense benefit to the Inquiry. The Report is solely the responsibility of Dr Swart and myself but we could not have carried out our work without the insight into urology practice provided by our Assessor, Mr Hanbury. I am grateful to you both.
3. I also wish to acknowledge the enormous contribution made by the Inquiry’s legal team, led by Ms Anne Donnelly and Mr Martin Wolfe KC. Dr Swart, Mr Hanbury and I recognise the long hours of preparation, analysis and high degree of forensic analysis demonstrated by the entire legal team and we are grateful to you all. Neither the legal team nor the panel could have processed, analysed or presented almost 700,000 pages of documentary evidence and witness statements without the high quality of work and the application of the Inquiry’s Secretariat, led by Mr Alasdair MacInnes. Everyone who has contributed to the work of the Inquiry is named in the Report and I thank them all, particularly those who have helped with the challenges presented in getting the Report ready for publication.
4. The Inquiry also wishes to thank Pi Communications and Gwen Malone stenography for their technical support in enabling access to the evidence presented during our public hearings. We appreciate their expertise in allowing members of the public who were not present in the chamber, to have an opportunity to see and consider the evidence of the witnesses as it was given to us. I also want to thank the staff here at Bradford Court for looking after us so well during our time in this building.
5. Finally, the Inquiry wishes to sincerely thank all those who provided evidence to us. Particular thanks must go to those who gave oral evidence. We appreciate that giving oral evidence is difficult, even more so when hearings are streamed online. The Inquiry process has been inquisitorial rather than adversarial in nature and both ourselves and Inquiry Counsel tried to reduce anxiety for witnesses as far as we could, bearing in mind that this was still a legal process and all oral evidence was sworn testimony. We thank too the legal representatives of the core participants and of others who gave evidence for the assistance they provided to the Inquiry.
6. I want to pay special tribute to those patients and family members who provided evidence to the Inquiry. They are at the heart of this Inquiry. From the very beginning, the Inquiry was determined to use the experiences of patients and their families to shape its work. We found their evidence powerful and moving. What they told us was vital and helped us to look at all other evidence through the lens of patient safety. Some of them have attended today and I know others are watching the live stream of these remarks. Their dedication to this Inquiry is testament to them and to their families and to their recognition of the need to ensure that others receive safe care. They are very welcome here today, whether in person or virtually.
7. It has been two years since we concluded our evidence hearings. In that time, we considered oral evidence, submissions, and a substantial volume of documentary material. Assessing that evidence and drafting the Report has been a considerable task.
8. Once the Report was drafted, and in accordance with my statutory duty to be fair, the Inquiry engaged in a warning letter process. This provided the opportunity for anyone who was to be the subject of potential criticism, direct or implied in the Report, to know what criticism was being made and to make representations about that criticism to the Inquiry. After considering those representations made to us, we amended the draft as appropriate and then finalised the Report. The Report is in four volumes and comprises five chapters, as well as an executive summary, introduction and a conclusions and recommendations section.
9. Throughout the Report we reached findings and made recommendations based on a detailed examination of the evidence. I urge those tasked with implementing change to read it in full, as what I say today cannot begin to summarise what is in a report that runs to four volumes. It is the content of the entire Report, the evidence referred to in it, our conclusions based on that evidence, together with recommendations that are of crucial importance.
10. This Inquiry was set up following a series of Serious Adverse Incidents (SAIs) involving one consultant urologist in the Southern Health and Social Care Trust (the Trust). It was set up under the Inquiries Act 2005, and its purpose is set out in its Terms of Reference. These can be found both in the Report and on the Inquiry’s website. Dr Swart and I are satisfied that we have addressed all the Inquiry’s Terms of Reference in the Report.
11. The SAIs that triggered this Inquiry revealed significant patient harm, as did other cases the Inquiry considered. Some of the patients died. The Inquiry looked at the harm or potential harm caused to patients, explored how that occurred and why the scale of harm was not fully recognised. The Inquiry did not set out to determine causation in each individual case, that was not our task, but we are satisfied from what we read and heard that patients were harmed.
12. Patients suffered delays in the diagnosis of cancer; they suffered delays in receiving treatments after they had been diagnosed; they sometimes received non-standard treatment without suitable explanations or adequate justification; the results of important investigations were not examined in a timely way; they were not scheduled for follow-up treatment, such as the removal of stents; and they were not kept fully informed about their treatment.
13. It goes without saying that if this harm had been prevented, then the patients and their families would have suffered less and the overall experience and outcomes of care would have been better. Accordingly, the Inquiry looked to see whether and how the harm might have been prevented. This meant that our work has been predominantly concerned with leadership and governance at the Trust.
14. The patients who were the subject of the SAIs, the lookback review and the Royal College of Surgeons’ review were all patients of Mr Aidan O’Brien and he is named in the Inquiry’s Terms of Reference. As I stated on many occasions, the Inquiry could not look at Mr O’Brien’s work to determine whether any individual’s treatment was appropriate. Instead, we looked at what the SAIs, lookback review and other cases told us about shortcomings in patient care in the Trust.
15. I wish to make it clear that Mr O’Brien was a skilled surgeon who did not set out to cause harm to anyone. Nonetheless, patients were harmed by shortcomings in his practice. A key finding is that the Trust failed to recognise that he was a doctor in difficulty and failed to manage him appropriately. Issues about his practice were known about for years, they were never satisfactorily addressed and there was a repeated tolerance of the risk his practice presented.
16. Mr O’Brien was, however, also a doctor who demonstrated a lack of insight into the fact that his practices were placing patients at risk of harm. The way Mr O’Brien carried out his practice, and his follow-up processes were unsafe. Failure to consistently follow evidence-based guidelines for treatment, delayed or absent triage, failures to review investigation results promptly, non-dictation of letters, poor record keeping and retention of notes outside the hospital, created direct risks to patients and undermined continuity of care.
17. While Mr O’Brien bears responsibility for how he operated his practice, the reality is that the Trust processes were insufficiently robust to identify or deal with the risk any shortcomings in his practice presented to patient safety. Even when an investigation into Mr O’Brien’s practice was launched under the framework of Maintaining High Professional Standards (MHPS) in late 2016, that process was badly handled. Moreover, it failed to recognise that what were termed ‘administrative’ failings could be indicative of wider problems with serious consequences. These were not investigated and ultimately patients were harmed. The Inquiry considers that this was a missed opportunity by the Trust. In Chapter 2 of the Report, we give details about the MHPS investigation and determined that the framework itself is not fit for purpose. We recommend that it be replaced and if that is not possible then we recommend a number of changes to it.
18. While some of the concerns about Mr O’Brien’s practice were known about for a long time, they were not addressed as they should have been. Risks were tolerated, warning signs were missed and opportunities to act were not taken soon enough. When formal action was taken it was badly handled.
19. This meant that patients were badly let down. They faced delays, poor communication and too often were left without the clear, high quality, timely care they should have been able to expect.
20. However, this Report is not simply about one doctor. The examination of Trust actions, or inactions in respect of Mr O’Brien, highlighted a number of problems with Trust governance and leadership. We set these out in the body of the Report and in our Conclusions and Recommendations section.
21. Our central finding is that the deeper causes of harm were systemic. Weak governance, poor oversight, ineffective escalation and underdeveloped leadership created the conditions in which patients could come to harm. Put simply, this was a failure to recognise risk early, or to respond to it properly.
22. Over the duration of our work the Inquiry heard from many witnesses: patients or their family members; clinicians; administrative staff; the senior management team in the Trust; Board members; representatives of NCAS (now PPA); the Patient Client Council and the Department of Health (the Department), as well as from Mr Aidan O’Brien.
23. The Inquiry was impressed by the dedication and commitment of staff in the Trust. While struggling to meet the daily operational challenges relating to the provision of healthcare in the face of an increasing demand with inadequate capacity to meet expectations, they were trying to provide the best care they could. Clinicians, support staff, leaders or managers did not set out to harm patients, nonetheless patients suffered harm.
24. The Inquiry considers that the right culture in healthcare needs to be one where all human effort and all systems are aligned towards a clear vision that supports the delivery of high-quality safe care. This can only be achieved through strong leadership and careful system design as well as a commitment to learn and improve. The Inquiry found that this was not the culture in the Trust.
25. There were clear weaknesses in governance and in how accountability and oversight were exercised. There was evidence of undue deference to seniority, evidence of professionals working in silos and failures of medical leadership at all levels.
26. The Trust Board did not fully understand or discharge its responsibilities. The Board did not adequately fulfil its duty to drive culture, strategy and for continual improvement. There was no effective assurance concerning the quality of care and a lack of critical oversight and challenge from the Board. It was too ready to accept matters at face value without probing and there was an absence of direction from the top.
27. Boards have a challenging task in balancing many competing demands and it is not surprising that our findings exposed a need for ongoing board development and training. This is particularly important with respect to understanding quality and safety issues.
28. If systems of governance had been better, there would have been earlier detection and more effective intervention when problems were detected. Some issues were known about but not recognised to present a risk to patients. Some issues were not identified, escalated or addressed effectively for many years. Their potential to impact patient safety was not fully appreciated, but it should have been.
29. Changing the Trust’s culture has to come from its Board. The Inquiry recognises and commends the notable changes and improvements that the Board has undertaken since the Inquiry began. Staff, clinical and operational alike, when they spoke to us, were generally receptive and displayed a willingness to learn and improve. We note that the Trust has demonstrated a willingness to embrace the need for cultural change and systems continue to develop.
30. We acknowledge that there is ongoing work in the Trust to move towards an open learning environment where all opinions are important and multidisciplinary teams share responsibility for outcomes of care.
31. We also recognise that the Department has been engaged in work to develop learning from inquiries in Northern Ireland, we commend this. We also note the discrete pieces of work reported in the Ministerial Statement in February 2026, including: the Serious Adverse Incident Framework; the establishment of Patient Safety and Quality Committees; a draft updated Board Member Handbook as well as the formal adoption of the Model Complaints Handling Procedure (MCHP) in January 2026.
32. We also consider that the recent “Being Human Framework” published by the RQIA is an excellent piece of work. It sets out what a good safety culture looks like under three domains, the first of which is a Commitment to Patient Safety and Staff wellbeing. This is important and as the document says it is of particular benefit to Trust Boards and is designed to enable and empower HSC staff, patients and families.
33. While we commend the work done to date, we say more needs to be done. The Inquiry considers that, while in each Trust a change of culture must come from the Board down, the Department has a role to play in changing culture across the entire healthcare system.
34. Our core recommendations for improvement are relevant to the Trust’s Urology department, to the Trust generally and more widely to health care in NI and in the UK.
35. We are conscious that this Inquiry is one of many across the UK into failures in healthcare. There have been multiple recommendations from those inquiries that have been implemented to varying degrees. This Inquiry has considered why recommendations in previous reports have not always achieved their intended outcomes. In light of this, rather than setting out a large number of recommendations, we have focused on a smaller number of priority actions designed to drive meaningful and lasting improvement. Our recommendations are not unduly prescriptive. We recognise that the Department and Trust will require expert guidance on how to best deliver the changes that are required. Accordingly, we have set out what needs to be done without being overly directive as to how that should be done and have made suggestions where we expect these to have the most impact.
36. Our recommendations are not only about addressing what went wrong in one service. They are about strengthening leadership, governance, culture and accountability across the system, so that patient safety is not simply an expression, but the clear and constant priority.
37. We have made three overarching recommendations focused on what matters most: putting patient safety at the centre of health and social care; strengthening leadership; and making much better use of information to protect patients and improve care.
38. The first recommendation is that the Department should formally declare patient safety to be the dominant and primary purpose of health care. That would send an important and unmistakable message to patients, families, staff and leaders across the system. Targets matter. Resources matter. But they must never obscure the central purpose of health care, which is to provide safe, high-quality care to patients.
39. This declaration should not be symbolic only. It is intended to help change the emphasis of the system and to support an open, learning culture. Managing money, meeting targets and protecting patient safety should not be seen as competing aims. They must be brought together around the same clear purpose: better and safer care. The declaration must be accompanied by a system-wide patient safety strategy.
40. Our second recommendation is for a comprehensive leadership development programme. Strong leadership is essential to safe care. Boards, senior leaders, managers and clinical leaders — including medical leaders — must be properly trained, supported and held accountable, so that they can recognise risk early, respond to it effectively and provide clear oversight. Leadership development must be sustained by regular training and updated to keep it both current and relevant to changes in the system.
41. Our third recommendation concerns data and information. Good information is one of the most important tools for safe and effective health care. Patients need information to understand the care they receive. Staff need information to understand their work and identify risk. Leaders need information to assure themselves that services are safe, effective and to drive improvement where this is needed. Information needs to be timely, accessible and support sound decision-making.
42. We recognise that large amounts of data are already collected across the health service. Collecting data is not enough. The right things must be measured, recorded and shared in ways that help services to identify harm, assure quality, learn quickly and improve. That will require a sustained programme of work by the Department and the Trust and real investment in data and information systems.
43. We have also identified seven areas for action. These areas overlap, as they must, because patient safety depends on the whole system working together. Action plans in each area should therefore be guided by the three overarching recommendations. The areas are:
a. Patient focus including complaints;
b. Organisational development and cultural reform;
c. Board and senior leadership development;
d. Governance;
e. Serious Adverse Incidents;
f. Medical leadership and the management of doctors in difficulty;
g. Urology and Cancer services.
44. The Trust and the Department have already made a number of improvements in many of these areas and we acknowledge that. However, the Inquiry’s view is that the patient voice is still not strong enough. We recommend that there is a much stronger emphasis on the patient voice. Patients and families must be treated as genuine partners in care — communicated with directly, listened to carefully and involved more fully when concerns arise, or when learning is needed. Complaints and concerns should be addressed earlier, more effectively and in a way that promotes both resolution and improvement. In that context, we also consider that the new draft SAI framework for Northern Ireland cannot be fully effective unless it is supported by a mandated duty of candour. We, like other inquiries, consider this a step that is long overdue and also ask that the legislation needed to enact such a duty be accelerated.
45. Further, we recommend a sustained programme of cultural and organisational development in the Trust. A just, open and learning culture does not emerge by accident; it requires leadership, clarity of purpose and investment in staff at every level. Everyone working in the Trust and throughout our health system should understand their individual and collective roles in protecting patient safety and in contributing to continuous improvement.
46. We make specific recommendations in relation to urology and cancer services, because it is in those services that the consequences of these wider failings were most sharply seen. In urology, we conclude that the service requires ongoing, practical support from senior management, the Board and the Department to stabilise the service, rebuild confidence and ensure that staff are properly supported to deliver safe care. A stable consultant workforce is essential and we recommend a clearer strategic approach to recruitment and retention, both within the Trust and across Northern Ireland. We also see an opportunity for the urology service to become a test bed for improvement — particularly in communication with patients on waiting lists, the management of clinical risk and the use of better information to support safer care.
47. In relation to cancer services, our recommendations are about ensuring stronger strategic leadership, clearer accountability and a sharper focus on quality and safety. We recommend that cancer services are led in a more integrated way, with stronger medical, nursing and managerial leadership working together. We also recommend better reporting to the Board, so that risks to the quality of care are seen earlier and acted upon more effectively. Importantly, we believe the lessons learned from urology should be used to strengthen cancer care more broadly, particularly in how information is brought together to give staff, leaders and patients a clearer understanding of the quality of care being provided.
48. Taken together, these recommendations are intended not simply to address the failures examined by this Inquiry, but to support a safer, more open and more accountable health service — one in which patient safety is not treated as one priority among many, but as the guiding purpose of the system.
49. We hope that the Inquiry’s hearings and the extensive evidence we have published will assist in both understanding what happened to patients in the Trust’s urology service and why. The Report being launched today is the product of substantial work and we hope that it receives careful and considered attention.
50. We urge those tasked with implementing change as an outcome from this Report to embrace it as an opportunity. Northern Ireland is a small region in national terms; our health service covers a population the size of a single large teaching hospital trust or one of the more recently formed hospital groups in England. We can assess the impact of the recommendations, monitor them, and review their effectiveness and, if they prove to be successful in achieving greater patient safety, replicate them across the region. In this way Northern Ireland can set a standard for health care across the UK.
51. As I conclude my remarks today, the Inquiry’s Report is formally published and will shortly be available on the Inquiry website. I once again wish to express thanks to all those involved in the Inquiry’s work.
52. Finally, I want to thank all of you for coming today, and those of you who are following this online, for the interest you have shown in the work of the Urology Services Inquiry.