Most of the reports on our many healthcare scandals can,if you want a sense of what they are all about but are too depressed to wade through their contents, be distilled into a few sentences or paragraphs.
The just-published report of HIQA's review into the Savita Halappanavar scandal (and let's take a break from calling it a tragedy as that implies it was sort-of nobody's fault) is no exception to this general rule.
Here are some key statements from this report:
"An open and just (safety) culture is not a 'blame-free' culture, but a culture that requires full disclosure of mistakes, errors, near-misses and patient safety concerns in order that system-based analysis can take place to identify learning."
And, a really key point: "It equally balances this with the holding to account of those whose competencies and performance has fallen below what might reasonably be expected of them."
And, HIQA reminds us, there is an 'urgent need for ownership, accountability and responsibility within the health service's national and local structures for implementation of critically important recommendations made by various review bodies and organisations.'
As reality checks go, they don't come blunter than that.
The HIQA report goes further than the HSE's own review into the Savita scandal, published in June.
Its message is that health authorities and managers should not simply say they are working to improve safety standards, but should be held to account to show that they are in fact doing so.
It stresses that while 'learning' is very important after adverse incidents, it is not enough for health systems simply to say they are learning from their (often costly) mistakes.
Unlike some previous reports into health scandals, the report does not mince words in outlining that in any proper safety-aware system, someone somewhere must be held accountable.
It criticises staff involved in Ms Halappanavar's care, and says there should be formal structures put in place to make health employers responsible for major safety deficits.
As a general rule, 'learning from mistakes' is a good idea and may well help improve the system, but if staff, whether at the coalface, or at managerial/admin level, are not asked to step up to the plate when things go seriously wrong, there can be no real learning.
That's not to say that most of the time, our hospital services are not perfectly safe. The HIQA report stresses that every day in our health system, there are patients who receive good, safe care at maternity units.
However, this statement can hardly be termed a ringing endorsement. HIQA goes on to state that its inquiry: 'has identified that the provision of maternity services, on occasion, may not be as safe as they should be or of sufficient quality.'
HIQA's point is that in the absence of effective monitoring of care standards in a system of checks and balances, the public cannot have any confidence that the services they are accessing are as safe as they should be. We can no longer just take it on trust anecdotally that everything's usually going to be all right.
Unfortunately, the acknowledged fact that most patients receive good care and that the skills of healthcare professionals are generally high is often used as a safety blanket by health authorities.
This tends to lead to a descent into 'groupspeak, which results in them paying what is essentially lip service to implementing safety improvements when things go wrong.
We need rigorous and accountable systems in place to ensure that procedures are there try to avoid people dying or getting damaged unnecessarily.
The HSE will tell us it is working towards this laudable goal of a safety-aware culture.
Unfortunately, the HIQA report tells us that the exact opposite is pretty much the case.
It is approaching the first anniversary of Savita's death.
A HSE review report into the scandal was published in June of this year. It identified very serious deficiencies in to Savita's care.
We were assured at the time that 'learning' was about to break out, with recommendations being acted upon locally and nationally and that things were improving. In fact, we have been assured all of this yet again this week by the relevant health authorities following the publication of the HIQA report.
Four months after the HSE report, what does HIQA tell us?
Well, it indicates that if if things are improving, change is happening very slowly or, in some cases, not at all.
The glacier-like process, if it can even be called a process, of putting in place safeguards has led to HIQA stating this week that the lack of safety and quality provisions in the maternity sydtem must be addressed as a matter of urgency.
Hopefully, following the limited learning from all the previous health scandals (many of them in maternity care), health authorities may this time try to understand the implications of what HIQA is saying.
Some HIQA examples of major current maternity care deficits are:
* Failure of many hospitals to act on implementing recommendations following the 2006 Tania McCabe case, a death from sepsis that was very similar to the Halappanavar scandal. Some hospitals 'had no comment' when asked about their implementation of the guidelines.
* Lack of national guidelines for managing sepsis.
* Deficiencies in critical care provision in maternity services.
* Lack of effective structures to monitor the performance and quality of maternity units.
* Nearly half of our maternity units do not even do the public the basic courtesy of publishing an annual clinical report on their results. In fact, it's difficult to access detailed annual reports for most units other than the three Dublin maternity hospitals.
* No agreed national dataset of quality and safety measures for maternity services in Ireland.
* No national key performance indicators for maternity services.
* No centralised and consistent approach to reporting on maternal morbidity (illness) and mortality.
* The HSE does not have arrangements in place to monitor the performance and quality of maternity services nationally.
* The report highlights inconsistencies in the provision of maternity services nationally and calls for a national maternity strategy. Further down the line, such an examination may conclude that some smaller maternity units outside the main cities may not be up to scratch, safety-wise.
It should also be pointed out that while systemic, policy, managerial and individual performance failures all contribute to health scandals, resource allocation, or the lack of it, also has a part to play.
Can any hospital system that has had at least one fifth of its budget removed over five years be as safe as it could be?
Does 'doing more with less' ultimately mean mean 'being less safe with less and hoping nobody will notice'?
It is therefore gratifying to hear that the HSE is calling for extra maternity staff to be provided in the wake of the HIQA report.
The Government must wake up to the fact that our health service can take no more austerity, as this is potentially contributing to patient safety risks.
The publication of health scandal reports, admittedly, causes much concern to competent and hard-working health staff who feel they are being tarnished by the omissions of others, or failures in the system.
The policy, operational and competence failures outlined in these reports do no favours at all to these conscientious health staff and do nothing for morale in an already beleaguered service.
It is in their interests, and the interests of patient safety, that these fault-lines in our health system, not just in maternity care, need to be be rectified.
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