Another damning report - will anyone be accountable?
Published 08/05/2015 | 02:30
It is always distressing to see patients being shockingly let down. But too often a death or injury is investigated in isolation and the wider underlying causes and contributory factors are not fully explored.
The investigation into the standards of care at Portlaoise Hospital promises to not just look at the maternity unit where five babies died in similar circumstances, but at its entire services and how it was run from the top down.
It will also be unique in that the Health Information and Quality Authority (Hiqa) has widened the net of responsibility to HSE corporate level and in the strongest terms castigates the failure of senior executives to act decisively to reduce the risk to patients.
The report will raise new questions about the role of smaller hospitals across the country and what level of service they should provide, given their funding and staffing numbers.
Portlaoise was one of a list of hospitals which was earmarked as needing downgrading in 2011 by the HSE. But former Health Minister James Reilly decided to exempt it because it had maternity and paediatric units.
Local TD and Minister for Foreign Affairs Charlie Flanagan made a strong case to stop what he saw as "dismantling".
We can expect a well-rehearsed response from the HSE and the Department of Health today about how Portlaoise is part of a hospital group, giving patients more protection in terms of shared expertise and manpower. But the reality is that all of this is yet untested and there is no reassurance that it will improve safety.
At the heart of the report are the bereaved families who lost five babies in similar circumstances. In all cases, the babies suffered a lack of oxygen after foetal distress was either not recognised or acted on during their mother's labour. The Hiqa report into the care of Savita Halappanavar already raised concerns about the monitoring of performance in maternity hospitals.
It found that eight of the 19 maternity units at that point did not produce an annual report, including Portlaoise Hospital. That Hiqa report was published in October 2013. Yet here we are again having to undergo another inquisition of basic safeguards.
It will shake the health service's complacent tone and rhetoric about maternity services.
But will it make any difference?
And will anyone take responsibility or assume accountability?