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HSE has not yet addressed key maternity care failures

Prof William Ledger, review group chairman and head of obstetrics and gynaecology at the University of Sheffield, and Dr Philip Crowley, national director, Quality and Patient Safety Directorate, HSE, at the publication of the National Miscarriage Misdiagnosis Review Report. Damien Eagers

THE HSE has made some changes since the miscarriage misdiagnosis scandal erupted last year -- but other key problems have not yet been addressed.

Since June 2010, when the scandal was first revealed, there have been two sets of new guidelines issued.

The first came in June 2010. It said that abortive drugs or surgery should not be recommended unless a diagnosis of a miscarriage had been signed off by a consultant-obstetrician. Up to then, a more junior member of the team, for example a registrar, could have recommended such a procedure.

The second set of guidelines came out in December 2010. Among the complex medical issues they addressed, a key change was that a second scan should be automatically offered to women after a first scan suggested there was no heartbeat.

Prior to that, mums-to-be had to request the second scan and in many cases insist on it. This was something that the women involved in the controversy had complained about.

However, the biggest problem identified by yesterday's report was the lack of formal training in early pregnancy scanning even by those who regularly performed the task.

Yesterday's report recommends that every member of staff involved in scanning should hold a formal certificate of qualification. Just 13pc of the doctors whose decisions were examined in the report had such a qualification.


The HSE has already begun training the remaining medical staff but it cannot say when this will be completed. This means that women suffering suspected miscarriages could still find themselves in a position where scans are being read by medics without the proper training.

Hundreds of staff will take part in the training scheme, and the first group is expected to finish by Christmas. They will also have to complete an "online training programme" which will improve their ultrasound and clinical skills.

Scanning experts known as sonographers are all already fully trained. But the new programme is about making sure other staff, including the consultants, are brought up to the required standard.

The latest report also dealt with out-of-date equipment. In six problem cases the scanning machines was more than five years old. The report said there should be a critical assessment of the machines at that stage. Health Minister James Reilly said all such machines would be replaced within weeks.

With regard to the key issue of a second scan, yesterday's report recommends that these be carried out automatically in a number of situations: where the first scan was conducted 'out of hours', where it was performed by a trainee doctor, or a doctor working alone. But it stopped short of making second scans mandatory in cases of suspected miscarriage.

This is despite the fact that in all 24 cases identified in the report, the women asked for additional scans after being told they miscarried, and in this way were able to find that their unborn child was still alive.

Irish Independent