Patient safety to become top priority for management across health system

The chief executive of every hospital or hospital group will be held accountable for the safety of their patients, Minister for Health James Reilly said last night. He said a national maternity services strategy would be developed "with urgency", and protocols would be in place "within 12 months" across the healthcare system to ensure every healthcare worker knew their responsibilities with regard to patient safety.

He was responding to the publication of the Hiqa report into the death at Galway University Hospital last October of Savita Halappanavar.

In its response, the HSE said it would appoint a senior official to oversee the implementation of the Health Information and Quality Authority's report's recommendations. "The HSE once again wishes to express its sympathy and regret for the shortcomings in the level of care afforded to Ms Halappanavar that contributed to her death. A process has already commenced within the HSE to complete a detailed analysis of the report's findings and recommendations."

Breakdowns in care

Describing the Hiqa report as “very disturbing” Dr Reilly said the HSE would have to learn lessons from such breakdowns in care and implement the lessons across the system. The HSE’s failure to do this was a “recurring theme” for him, he said.

“I deeply regret that our health service failed in such a catastrophic way to deal with the care of Savita Halappanavar,” he said. “There is one page in the report that has a graph in it which shows over the first four days of the late Savita Halappanavar’s care there were 13 different points where actions might have been taken that might have changed the very tragic outcome.

“My immediate response is that patient safety has to be seen as paramount in our service. As such the next national service plan will have a very strong emphasis on patient safety. It will be an integral part of it.

“I think in the past there may have been an attitude among management that patient safety was an issue for clinicians alone. It is not. It cannot be the case.

So each CEO of each hospital and each new hospital group, it will be made very clear to them that this is a core part of their responsibility and has to be their primary concern and they will be expected to ensure the safety of the patients that attend their hospital, supported by their clinical directors.

“What deeply disturbs me is the fact that we had a similar case a number of years ago where a young woman, Tania McCabe, lost her life and that of one of her twins.

"That lesson certainly was learnt in that hospital [Our Lady of Lourdes Hospital, Drogheda] but it has been a recurring theme of mine about the HSE's failure to transpose excellence across the system, that when lessons are learned in one place they're not learned right across the system, when people are doing things well in one place that that's not transposed across the system."

He said he would ensure all recommendations were implemented "as soon as possible".

Maternity plan

Referring specifically to the recommendation that a national maternity service strategy be developed, he said: “We do need to develop a full national maternity services plan and we will do that with urgency.”

He stressed, however, that Ireland remained one of the safest countries in which to have a baby.

“But clearly an incident like this demonstrates where human failure has such a catastrophic effect and not just by one person but by several people involved in the care of the patient.”

He said he had heard nothing back from either the Irish Medical Council or the Irish Nursing Board following his referral to them, in June, of the HSE investigation report into her death.