THE Chief Medical Officer in the Department of Health has said the incidents surrounding the deaths of four babies at Portlaoise Hospital were not caused by a lack of staff but rather a culture within the hospital that meant workers did not always communicate effectively with patients.
Dr Tony Holohan has outlined guidelines that he says will empower the health watchdog and ensure that there is better transparency between medics and patients.
In his report for Health Minister James Reilly, Dr Holohan states an "open disclosure" policy must be established in hospitals in order to prevent any attempts by medics to keep patients in the dark over issues related to their care.
Dr Holohan's report was compiled in light of the Midlands Regional Hospital scandal, in which the hospital investigated the deaths of four babies over the space of six years without informing the parents of the deceased infants that any investigation into their child's death was going on.
The death of a fifth baby is now being investigated.
This failure to communicate effectively with staff was described by Dr Reilly as "appalling".
Speaking on RTE's 'This Week' yesterday, Dr Holohan said the 86-page report he presented to Mr Reilly would help to create "a safety net at local and national level".
He said the guidelines would ensure that hospitals issued a public patient safety statement each month out-lining transfer rates and incident rates.
He added that a better surveillance system would be put in place in order to ensure that the Health Information and Quality Authority (HIQA) had access to all information available to other health bodies.
Dr Holohan said the new system would enable the HIQA to access an entire body of data as opposed to previously where "each organisation had a piece of a jigsaw" as to what was going on.
Plans are also in place to merge Portlaoise Regional Hospital and the Coombe in Dublin, which Dr Holohan said would ensure that top quality was provided on a local level but also enable medical professionals to receive specific training across a variety of areas.
In his report for Dr Reilly, Dr Holohan explicitly states that a policy of transparency with patients must be implemented as soon as possible to prevent a repeat of the scandal.
Dr Holohan said Portlaoise-based hospital conducted reviews into incidents in a "less than timely manner, often well after the incident had taken place".
He also said there was "no evidence" that hospital staff had communicated effectively with families and that often relatives with "very real and reasonable concerns" were left without answers.
He said the fact families were kept in the dark shows "the culture in the hospital was not one which leads to the right people stepping in and stepping up at the right times".
Dr Holohan also recommends that all perinatal deaths and maternal deaths that occur during a low-risk pregnancy be listed under the medical term 'never event'.
The classification refers to medical errors that result in fatality or profound disability.