Serious safety issues in Portlaoise

  • Niall Hunter, Editor

A report into the deaths of a number of infants at Portlaoise Hospital has found maternity services at the hospital  are neither safe nor sustainable under current governance arrangements.

The damning report, carried out by the Department's Chief Medical Officer, Tony Holohan, will have implications for the future of other smaller maternity units around the country. Health Minister James Reilly has said the HSE will be asked to review services at similar sized maternity units around the country.

It is now thought that the Portlaoise findings will lead could lead to smaller maternity units being closed and/or incorporated into larger hospital networks. The future of other smaller units such as Wexford, Clonmel and Castlebar could come under scrutiny.

The Minister said there were implications in the report for other services at the hospital and for other maternity services in the country.

In addition to highlighting serious safety shortcomings, the Portlaoise review also found that the parents of infants who died unexpectedly were treated in a poor, and at times 'appalling' manner in their dealings with the hospital. Information which could have been shared with the parents about the deaths was not provided by the hospital.

The review also found that Portlaoise Hospital failed to act on safety issues in its maternity unit. Poor maternity outcomes that could have been prevented were known by the hospital, but not adequately or properly acted on.

The review said staffing shortages were not the main cause of the safety issues at Portlaoise. Staff at Portlaoise had in recent years warned of staff shortages leading to safety problems.

The report says clear failures in the management of patient safety at Portlaoise occurred at both local and national level.

Due to the serious safety issues highlighted, the HSE is sending in a transitional team which will run maternity services in Portlaoise.

Following the issuing of the CMO's report, the safety body HIQA will now carry out a broader inquiry into maternity care at Portlaoise, dating back of a number of years.

Portlaoise services are now to be integrated with those of the Coombe Hospital in Dublin.

Minister Reilly said he was conscious thst recent events in Portlaosie had damaged public confidence in the hospital. However, he said with the establishment of a new clinical network with the Coombe, the hospital would be supported to ensure improved and safer maternity services.

He said in looking at other maternity services, the HSE would consider the incorporation of them into managed clinical networks within hospital groupings.

Dr Reilly said he had ordered a swift analysis of midwifery staffing across the country.

The Minister also indicated that some doctors and midwives at Portlaoise will face disciplinary probes by their regulatory bodies on foot of the infant deaths at Portlaoise and how they were handled.

The Clinical Director at Portlaoise, Dr John Connaughton has unreservedly apologised to ther families affected by the scandal.

However, he rejected suggestions that staffing and resource shortages contributed to the adverse incidents investigated at Portlaoise.

The CMO's review followed a RTE Prime Time investigation into the deaths of four infants at the hospital, the last of which occurred in 2012. The programme highlighted failures by hosital staff to act on warning signs in he lead up to theborths of ther babiers who died.

A further infant death at the hospital is also being investigated.

Commenting on the report, Patient Focus said since the airing of the Prime Time programme a large number of women and families got in touch with it recounting 'heartbreaking stories' of what they believe were unacceptable levels of care at Portlaoise.

"The women and families are devastated that this may have led to the unnecessary deaths of and/or damage to their own babies delivered there. They are further dismayed by the seeming lack of information provided to them when they experienced the death of or damage to a baby."

Patient Focus said it was deeply concerned by the seeming inaction by the externally based risk management department in relation to serious outcomes for babies born in Portlaoise.

"Therefore it is with great relief that we welcome the initiatives detailed by Minister Reilly today."

Patient Focus called on the HSE to set up a helpline for women and families with concerns about their own care or the care of their baby at all hospitals and to contact anyone who may have been involved in an adverse event or review or investigation at any Maternity unit in the past.

HIQA said it had received a copy of the Chief Medical Officer's report and also that the Minister for Health had written to it requesting it to undertake an independent investigation into Portlaoise Hospital.

"The Board of HIQA will consider the Minister's request along with the CMO's report and will determine the nature and extent of any subsequent investigation," HIQA said.

Fianna Fail Health Spokesperson Billy Kelleher said it was clear that the families were treated 'scandalously' and that there was simply no justification for the withholding of information from them.

"The Chief Medical Officer's conclusion that maternity services cannot be regarded as safe and sustainable must be acted upon urgently. Mothers, babies and families are entitled to expect safe care at Portlaoise and the HSE must move swiftly to provide this."

The Department of Health and HSE were already carrying out a review of maternity services in the West-North West region and were planning a national maternity services review, prior to the publication of the Portlaoise findings.

A national maternity services strategy is to be published later this year.

Safety last - the Portlaoise findings

Patience wearing thin on safety guarantees



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