Damning report on Portiuncula Hospital recommends 150 maternity improvements
The long-awaited maternity services report highlights familiar health service failings, writes Priscilla Lynch
Last week finally saw the publication of the long-awaited Report of the External Independent Review of Maternity Services at Portiuncula University Hospital, which was commissioned more than three years ago.
The review team, headed by James Walker, Professor of Obstetrics at the University of Leeds, examined the care of 18 babies who had adverse outcomes and the state of maternity services at Portiuncula Hospital during the period 2008 to 2014.
The report contains a series of damning findings and makes more than 150 recommendations.
This review was commissioned following a preliminary review into the care provided to six women whose babies were referred from Portiuncula for therapeutic hypothermia (head cooling) in 2014. This is typically a treatment for babies who were deprived of oxygen at birth and these numbers were higher than average.
The review team found that of the 18 cases reviewed, serious errors in management occurred in ten cases that would have probably made a difference to the outcome for those babies.
Babies died in six of the cases, and others were left with serious disabilities. In four of these cases there were significant failings in the care provided to those babies.
Among the report's key findings were failures to recognise in time when the reviewed women's labour was going wrong, poor communication and team working between medical staff, delays in escalation of concerns to more senior decision makers, delays in intervening in deteriorating circumstances, poor CTG (trace) interpretation, and concerns relating to the administration of oxytocin, a drug used to speed up labour.
The review found that Portiuncula maternity unit had a shortage of senior midwives and consultants, inadequate specialist training of many staff, not enough senior decision makers on the labour wards, confusion over who was in charge, and poor governance structures during the time period.
The report raised concerns around the way many of the families were communicated with during or after their time in hospital. Shockingly, some families said they received calls from staff at Portiuncula seeking information about the welfare of their baby after the baby had died and, on one occasion, on the day of the baby's funeral.
Since the original concerns were identified in late 2014, the Saolta Group and Portiuncula Hospital say they have put in place a significant number of measures to improve patient safety and address the majority of the issues raised in this report. These measures include increased midwife and consultant numbers, improved specialist training and better reporting structures.
It is also important to note that the review team found the care provided in Portiuncula was of a high standard for the majority of women who had normal labours there.
Almost 15,000 babies were delivered at the hospital during the review period, 2008-2014, and its perinatal outcomes were in line with national norms.
So what happens now?
Work has begun to develop a fully-integrated maternity service between Portiuncula University Hospital and University Hospital Galway. The maternity services in both hospitals will be managed jointly with future joint clinical appointments and fully integrated training programmes and risk stratification of complicated pregnancies.
This is in line with the 'hub and spoke' model for maternity services recommended in the National Maternity Strategy, and is what happened with the maternity unit in Portlaoise Hospital, where, following reports into a number of baby deaths, the unit now operates under the control of the Coombe Hospital Dublin.
A key issue highlighted by the Portiuncula report, which is also at the heart of several other recent healthcare scandals, is the lack of open disclosure in our health services.
Open and honest communication and explanation when mistakes and errors in care have been made is supposed to be available to all patients. However, parents in the Portiuncula review reported being fobbed off, and not told that there had been errors in the delivery or care of their babies.
In the vast majority (17) out of the 18 reviewed cases, open disclosure was found to have not happened. Open disclosure became official national policy in the HSE in 2013, but crucially it is not yet mandatory.
Following the lack of disclosure of the smear test audit findings for the majority of the 208 women involved in the cervical cancer screening controversy, Minister for Health Simon Harris has now said he will progress legislation to make open disclosure mandatory in our health services.
This legislation had previously been promised by Leo Varadkar when he was minister for health but was watered down to remain voluntary last year.
The publication of the Portiuncula report has also highlighted the need to speed up the implementation of the National Maternity Strategy, which was originally published in January 2016.
Its recommendations for a more modern integrated maternity service were widely welcomed though, like most healthcare strategies in Ireland, roll out has been slow.
It shouldn't take a scandal to force improvements in staffing and structures of our maternity units, which have long been at the bottom of the health service priority list.
As the Maternity Strategy states, all women in Ireland should have access to safe, high-quality, nationally consistent, woman-centred maternity care.