HIQA has slammed maternity units for failing to properly implement recommendations for dealing with seriously ill maternity patients that were published nearly six years before the death of Savita Halappanavar at University Hospital Galway.
Its report on the Halappanavar case warns that our maternity services may on occasion, not be as safe as they should be and may not be of sufficient quality.
The HSE published guidelines in 2007 for dealing with critically ill pregnant women following the death of Tania McCabe from septic shock at Our Lady of Lourdes Hospital, Drogheda. Her infant son also died at the hospital.
HIQA, in its newly-published report on Savita's death in October 2012, said the Tania McCabe guidelines should have been implemented nationally, and many of these guidelines would have had particular relevance to Savita's case.
However, the safety body, in compiling its report, said it found an uncoordinated approach among maternity units to the implementation of these vital guidelines.
It asked the HSE to find out how the Tania McCabe recommendations were being implemented in all 19 public maternity units. Only five units were able to provide a detailed status update for all 27 recommendations, with one hospital reporting that 24 out of the 27 were implemented.
The five hospitals who provided detailed updates were Mullingar; the Coombe; the Rotunda; Drogheda and the Regional Maternity in Limerick, according to HIQA.
HIQA said the 14 other units reported their status against a different investigation, 'had no comment' , reported that evidence for implementation was not in existence, reported a number of local guidelines and/or training programmes they had put in place in response to the 2007 recommendations or reported that recommendations were reported on and followed-up and actioned through the minutes of meetings."
"This is unsatisfactory and concerning," HIQA commented.
The remaining hospital units, including Holles Street in Dublin, it said, reported as number of local guidelines and/or training programmes they had put in place in response to the 2007 recommendations. "Others reported that recommendations were reported on and followed up and actioned through the minutes of meetings."
Speaking at the launch of the report, HIQA Director of Regulation Phelim Quinn said in five instances there was no evidence of the recommendations having been implemented.
He said there was limited evidence for the national implementation of the 2007 recommendations and there were striking similarities between the Tania McCabe and Savita Halappanavar cases.
Mr Quinn suggested that proper implementation of the 2007 guidelines may have prevented Savita's death, as staff could have learned from the Tania McCabe case.
HIQA said the lack of a coordinated approach to the implementation of the recommendations of the Tania McCabe inquiry 'raises a fundamental and worrying deficit in our health system - namely the ability to implement and apply system-wide learning from adverse events across the system in a timely and appropriate manner in order to prevent the recurrence of patient safety events that may cause harm, or worse, to patients.'
HIQA wants the HSE to develop a national clinical guideline on the management of sepsis.
The HIQA report is critical of the lack of a coordinated approach to quality and safety standards in the maternity services nationally.
HIQA says it is impossible at this time to properly assess the performance and quality of the maternity service nationally, due to the wide variation in local clinical and corporate governance among the 19 maternity units in Ireland.
The report highlights inconsistency in the provision of maternity services nationally in terms of variations in the models of service provided; resource allocations, and differences in the way quality and safety standards are monitored.
The report says there are inadequate arrangements in place to monitor the performance and quality of the 19 units, and an ambiguity in accountability arrangements nationally.
HIQA pointed out that there is a failure to identify and address emerging patterns in sepsis as a key cause of maternal deaths, and eight of the 19 maternity units do not produce any form of annual clinical reports with their clinical results.
It said there is no agreed national dataset of quality and safety measures for maternity services in Ireland.
The report also pointed to deficits in critical care services, in information on maternal morbidity (illness) and said there was no formal process for the implementation of recommendations of the Confidential Maternal Death Inquiries.
The report also shows that Limerick, the Rotunda, Holles Street and Portlaoise Hospitals did not have 24/7 access to on-site diagnostics for critically-ill maternity patients, while Limerick, the Rotunda, Holles Street and the Coombe did not have on-site access to intensive care/high dependency beds.
The report noted that the HSE had in April introduced an national early warning system for critically ill maternity patients.