Expert team calls for full review of care in nine more maternity cases
Nine families with concerns about the standards of care they received in maternity units are to have their cases reviewed, it emerged yesterday.
The cases have been referred for a systems analysis review - involving a team from the hospital and other areas of the HSE - following an examination of medical notes by a group led by National Maternity Hospital obstetrician, Dr Peter Boylan.
Dr Boylan reviewed the case notes of 28 families who contacted a helpline last year in the wake of the Portlaoise Hospital scandal involving the death of five babies. They were seeking answers about the care given to babies and mothers.
The families, who were not consulted during the desktop review, have received an apology from the HSE for having to wait over a year for the report to be completed.
Each family has now been given their own individual report with the comments and findings of Dr Boylan and other obstetricians.
The report said that in 11 cases the group concluded there were "possible issues" relating to care and said nine needed to be fully reviewed.
The 28 cases involved 23 from Portlaoise Hospital, three from Limerick and two from Mullingar Hospital spanning 1985 to 2013.
They included 14 stillbirths or neonatal deaths, one infant death, a retained swab, a wound abscess, an undetermined brain condition and a massive osbtetric haemorrhage.
All 28 families were sent their reports yesterday and will be offered one-to-one consultations as well as counselling if they want it.
Dr Boylan's report made a series of wide-ranging recommendations, including a call for all maternity units to do regular audits of adverse events and analyses of what went wrong.
He said his data from individual maternity units should be fed into an annual audit of all services without delay.
Each hospital needs to have a formal system of review of adverse events and the results of these need to be given to patients within two months of the incident.
Hospital staffing needs to be adequate and agency doctors or locums should not be relied on to fill in at Bank Holidays or weekends.
Every junior doctor should be in a recognised training scheme and there needs to be ongoing mandatory training programmes for all clinic staff on the day-to-day care of pregnant women.
Every maternity hospital should have a number of midwives trained to ensure that high quality obstetrical ultrasound is available on a routine basis during the working week and on an on-call basis.
Another 108 families who also rang the helpline are having their cases analysed at the hospital where they were treated.
If the review team thinks there are more questions, it will send the individual case on to Dr Boylan and his group to conduct an examination of medical notes.
The review may still not satisfy the concerns of some families, who have questions over the accuracy of their medical note.