The HIQA report into the death of Savita Halappanavar recommended the development of a National Maternity Strategy. It took the deaths of Sally Rowlette and Dhara Kivlehan, and the exposure of serious deficiencies in maternity care at the Midland Regional Hospital, Portlaoise, by RTE's Prime Time, to push the State into developing the Strategy.
These deficiencies resulted in the deaths of several babies and it was the courage and persistence of grieving mothers, in particular Roisin Molloy and Shauna Keyes who engaged with RTE's Prime Time, that provided the final impetus.
Implementation of the Strategy will prove to be a fitting memorial to those who died.
The Strategy has been widely welcomed, including by the Institute of Obstetricians and Gynaecologists. Governance, both at clinical and corporate level, is a key element of the Strategy. Without proper governance none of the rest of the Strategy, including recruitment of extra staff and investment in infrastructure, is going to be successful in minimising the risk of similar tragedies in the future.
The publication of the National Maternity Strategy and the Banking Inquiry on the same day revealed interesting parallels in failures of governance, each with their own type of catastrophic results. Just as the Banking Inquiry found that banking board members lacked the necessary skills to recognise potential risks, so the boards of those hospitals where these tragedies occurred lacked medical input from Obstetricians able to understand the potential risks in their maternity units.
Indeed, many of those hospitals did not, and still don’t, have any board to whom managers are accountable. Similarly, there was a lack of proper audit in both the banks and the relevant hospitals.
Significantly, all of the recent problems in our maternity services have been in maternity units which are integrated into, and not co-located with, general hospitals.
Maternity care comes down the list of priority when it comes to scarce resources in these hospitals. Midwives get re-allocated to surgical or medical wards, operating theatres get used for non Obstetrical or Gynaecological procedures and operating lists get disproportionately cancelled.
The model of governance outlined in the Strategy calls for the co-location of maternity hospitals with acute general hospitals, not their integration, and also calls for the wider introduction of the Mastership model of clinical governance.
The Mastership model currently operates in the three large Dublin Maternity Hospitals and, in response to clinical governance problems in Portlaoise, the Coombe has been invited to provide governance there.
The Master is a senior clinician who is accountable to the board of the hospital, of which a significant number are doctors, including former Masters, and covering all relevant specialties. The Master is assisted in their role by a Director of Midwifery, and appropriate management staff. It is the Master however who is ultimately responsible for the standard of clinical care in the hospital.
Audit forms an integral part of governance in this model. Each year for example an outside assessor, usually from the UK, reviews the clinical results from the three Dublin Hospitals, and more recently Cork as well, and critiques the results at a meeting of all Obstetricians in the country.
Midwives and support staff also attend these meetings which have been an annual fixture for at least the past seventy years. Co-location, rather than integration, allows the maternity hospitals to have a separate board, a separate budget, and proper governance arrangements at both clinical and corporate level. There is therefore greater transparency when it comes to accountability.
The National Maternity Strategy will result in the adoption of this model of governance, co-location and the Mastership model, around the country with maternity units having their own separate budget, and boards to whom the Master is accountable.
This system has been around for the past 260 years since it was first started in the Rotunda. It works. The National Maternity Strategy provides a real opportunity to fix the ills in our maternity services, but without the proper governance structures in place that won’t happen.
Dr Peter Boylan is Chair of the Institute of Obstetricians and Gynaecologists and a former Master of The National Maternity Hospital