Pressure on HSE to reveal all maternity unit failures
Demand follows damning Hiqa report into Midlands General Hospital
A register of serious incident reviews across all maternity units should be published by the HSE, according to a patient advocacy group that helped families to expose the damning failures at the Midlands General Hospital in Portlaoise.
The call for the register was made by Patient Focus following the report by health watchdog, Hiqa, that serious concerns over patient safety at the hospital were ignored for more than a decade, and led to the deaths of eight babies.
The report, which followed the deaths of five babies at the Midlands hospital found HSE managers at a local, regional and national level were aware of patient safety risks at the hospital but failed to act. The deaths of three other babies are now among 28 infant deaths being clinically reviewed by a team led by obstetrician Peter Boylan.
"People should know where serious incidents are occurring in the various regions in the country, the nature of the problem and where they occurred," Sheila O'Connor of Patient Focus told the Sunday Independent. "This information should be publicly available."
Figures obtained by the Sunday Independent last month revealed that the HSE is currently investigating 49 "serious incidents" across the country's 19 maternity hospitals, relating to deaths of mothers and babies, stillbirths, "poor outcomes" for mothers and babies, and "therapeutic hypothermia". A further 10 "serious incident" reviews were completed.
The experience of patients was central to the health watchdog's report, which raised serious questions over the "poor leadership" displayed by those at the highest levels of the HSE, even though concerns had been raised over the years by staff, patients and in official reports.
The manner in which these parents received their dead babies was described as "grossly inappropriate and extremely traumatising". In one case, parents described how their baby was brought to them in a metal box on a wheelchair covered with a sheet and pushed by mortuary staff.
The report was commissioned in the wake of an RTE Prime Time programme last year that raised questions over the deaths of five babies. Despite the seriousness of the patient safety concerns at the hospital at the time of the programme, the report said there was no evidence that key senior HSE managers had visited the hospital in the immediate aftermath of the broadcast to assess the situation in the maternity services.
Overall, Hiqa was unable to "definitively conclude" that services at the hospital are safe" for women giving birth today, and said similar problems are "very likely to occur elsewhere".
It found the Midlands Hospital failed to comply with 27 national standards for better, safer hospital healthcare.
The HSE was found to have failed to comply with 19 of those national standards, including not monitoring Portlaoise, its services, staff and resources and did not prioritise a culture of quality and safety. HSE Director General Tony O'Brien said on Friday he would not be resigning.
Health Minister Leo Varadkar accepted all of the report's findings and recommendations. However, the HSE "contends that much of the narrative in the report lacks context or balance".
Mr Varadkar has said if services at Portlaoise are not viable because there are not enough patients to support them those services will have to be discontinued.
He said the hospital was "allowed to drift for decades" without clear direction or support.
"It's clear to me that, on occasion, patient safety and quality came second to other interests: institutional, staff, corporate and political. This has to change, not just in Portlaoise but nationwide."