Report says maternity service not safe or sustainable

The maternity service at the Midland Regional Hospital Portlaoise cannot be regarded as safe and sustainable within its current governance arrangements, a Department of Health report into the deaths of a number of infants at the hospital has found.

The report was ordered after an RTÉ television Prime Time programme on January 30th last reported on the deaths of four babies between 2007 and 2012.

The report drawn up by the department's chief medical officer Dr Tony Holohan also said that families and patients had been treated in a poor and, at times, appalling manner, with limited respect, kindness, courtesy and consideration.

It said that information that should have been given to families had been withheld for no justifiable reason.

Behaviour
"It is difficult to explain some of the behaviour that was attributed to staff by the patients, as well as by some of the staff that we met. We have not sought to validate each statement made but we have no reason to doubt it. Nothing we came across could be regarded as providing an acceptable explanation."

Dr Holohan’s report said that poor outcomes that could likely have been prevented were identified and known by the hospital but not adequately and satisfactorily acted upon.

“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.”

A transition team has been appointed by the HSE to run the maternity unit at the hospital, which in future will form part of a managed clinical network under the auspices of the Coombe Women’s and Infants’ University Hospital.

Dr Holohan’s report said many of the staff in the unit did their best in challenging circumstances.

“However it is evident that on occasions, both standards of care and staff behaviours, particularly their interactions with families following adverse events were less than acceptable.

“It is noted in this report that circumstances including poor leadership outside of individual clinician control did not support or help lessen the risk of such events.”

The report also said that many organisations, including the hospital, had partial information regarding the safety of the maternity service at Portlaoise that could have led to earlier intervention had it been brought together.

It also said external support and oversight from the HSE should have been stronger and more proactive, given issues that were identified in 2007 after a controversy surrounding cancer services.

“Dealing with issues of patient safety requires action on the basis of intelligence and evidence. A central finding of this report was that a profile of safety of maternity service within the hospital could have been created from easily-available information.”

Weaknesses
"The final analysis of this report identified fundamentally that problems arose from systemic weaknesses of governance, management and communications for dealing with critical situations such as arose in late August 2007.

“At the time it was detailed that these issues needed to be tackled to avoid a recurrence. Portlaoise hospital does not appear to have been provided with the oversight and supports that could have reduced risk, increased patient safety and protected staff morale.”