HSE failure to implement findings is unacceptable

The report by the Department of Health's chief medical officer (CMO) into four perinatal deaths at Midland Regional Hospital Portlaoise suggests the failures by the Health Service Executive are even greater than originally exposed by RTÉ's Prime Time programme.

According to the Prime Time report, some of the babies died because of a failure to act on signs of foetal distress. An especially worrying aspect was how the investigation into baby Mark Molloy's death discovered that recommendations made following the death of another baby at Portlaoise in almost identical circumstances two years previously had not been implemented.

We now learn from the chief medical officer, Dr Tony Holohan, that the risk management resources at Portlaoise were downgraded from 2010. The network manager, general manager and risk manager who had dedicated time in the hospital (two days a week), retired. None of these was replaced.

As the CMO notes: “Dedicated access to this resource diminished from 2010 due to retirements and the broadening of the remit of this service to cover the entire Dublin Mid-Leinster region.”

A dedicated risk manager/ risk co-ordinator was not appointed until July/August 2013. In other words, some four years after all 32 midwives made their concerns about the safety of mothers and babies at the hospital formally known to management, the risk management resources at the hospital were significantly diluted. A hospital with a maternity unit known to be in serious difficulty was effectively stripped of risk management expertise.

"The lack of on-site expertise and poor tracking and monitoring systems for risk is unhelpful," Dr Holohan states. Worryingly, he adds: "While systems have been strengthened recently, the overall picture is unsatisfactory and is not likely to be sustainable over time."

Sustainable
Elsewhere, he says, "the Portlaoise Hospital Maternity Service cannot be regarded as safe and sustainable within its current governance arrangements as it lacks many of the important criteria required to deliver, on a stand-alone basis, a safe and sustainable maternity service".

Will yesterday’s secondment of senior managers from else- where be enough to stabilise the unit? Can its inclusion in the governance structure of the Coombe hospital in Dublin ensure patient safety?

There must be a serious doubt that this is enough.

Without the immediate introduction of more staff in the unit, so there is a ratio of one midwife to 29.5 births – which according to the Irish Nurses and Midwives Organisation requires 33 extra midwives for Portlaoise – how can the HSE tell women due to give birth there that they are safe?

The track record of HSE failure to implement the findings of important investigations into critical incidents in our hospitals is unacceptable. And politicians must recognise that the reflex exercise of parish pump politics in campaigning against the closure of smaller hospital units may achieve a useful electoral aim, but may well put lives at risk.