Safety last - the Portlaoise findings

  • Niall Hunter, Editor


The overall conclusions of the Department of Health CMO's report on a number of infant deaths during or immediately after childbirth at Portlaoise Hospital are:

1. Families and patients were treated in a poor and, at times, appalling manner with limited respect, kindness, courtesy and consideration.

2. Information that should have been given to families was withheld for no justifiable reason.

3. Poor outcomes that could likely have been prevented were identified and known by the hospital
but not adequately and satisfactorily acted upon.

4. The Portlaoise service cannot be regarded as safe and sustainable within its current governance arrangements as it lacks many of the important criteria required to deliver, on a stand-alone basis, a safe and sustainable maternity service.

5. Many organisations, including Portlaoise Hospital, had partial information regarding the safety of the maternity service that could have led to earlier intervention had it been brought together.

6. The external support and oversight from HSE should have been stronger and more proactive.

More specific findings include:

* There was a sharp rise in the number of negligence claims relating to childbirth at Portlaoise in 2007, coinciding with an increase in birth numbers. There was inadequate collection of data at the hospital in recent years which would have shown an increase in adverse events.

* Where families of babies who had died tried to get explanations from staff, there were incidences where people felt 'backs were turned'; honest accounts of the circumstances leading to the deaths were not given; 'unprofessional behaviours and language' were frequent; there was insensitivity and lack of empathy; younger patients felt patronised by staff; senior clinical staff in more than one case invited patients to 'sue' if they weren't happy.

* There were clear and unacceptable failures to disclose to patients that serious events had taken place or that reviews had been completed of such events; vital information was withheld from families; families blamed themselves for events in which they had no responsibility.

* Reviews carried out by the hospital into adverse incidents took too long, sometimes over two years, and flaws with these reviews were identified.

*While safety risk management processes at Portlaoise have improved recently, the overall picture is still unsatisfactory and is not likely to be sustainable over time.

* Staff involved in risk management at Portlaoise who retired were not replaced.

* Care deficiencies surrounding the infant deaths included failure to act on clinically significant signs and symptoms, including non-recognition of fetal distress; misjudgements made in care included inappropriate use of oxytocin in labour; senior staff not contacted/unavailable when situations were deteriorating.

* The way in which information passed between staff between shifts, on transfer across the hospital and when escalation of care was required, was not carried out in a standardised way.

* In only one of the infant deaths reviewed was the HSE's external national incident management process brought in. Safety lessons appear not to have been learned from a previous scandal at Portlaoise, relating to breast cancer diagnosis, which emerged in 2007.

* HIQA had been raising safety concerns with Portlaoise dating back to 2011.

* There are large gaps in midwifery leadership positions due to non-filling of posts and long-term sick leave -this diminishes clinical supervision and affects patient safety.

* There was evidence of breakdown in relationships betweeen senior management wnd clinical teams at the hospital.

* Portlaoise 'lacks many of the important criteria' on a stand-alone basis to be a 'safe and sustainable maternity service in the 21st century'.

* Many of the staff did their best in challenging circumstances. "However it is evident that on occasions both standards of care and staff behaviours, particularly their interactions with families following adverse events, were less than acceptable."

* Overall lack of a patient safety culture at Portlaoise.

The main recommendations of the report include:

* The hospital must apologise unreservedly to all families and patients affected by the adverse incidents.

* HIQA must immediately assess the patient safety culture at Portlaoise and undertake a full investigation into Portlaoise maternity care and other issues at the hospital. HIQA should develop national standards for the review of adverse hospital incidents.

* A team should be appointed to run Portlaoise's maternity service prior to its linking with the Coombe.

* Other small maternity units as well as Portlaoise should be incorporated into clinical networks of hospitals.

* Procedures should be put in place to ensure that midwives are in compliance with practice standards.

* Senior management at Portlaoise should be supported to deliver a safe effective service.

* Every maternity unit should be obliged to publish a patient safety statement, providing information on key safety issues. This should be updated each month.

* There should be better and more accurate collection and calculation of data relating to infant mortality.

* Healthcare professionals performing fetal assessment should engage in regular multidisciplinary training.

* The HSE should ensure that systems are in place to ensure that senior consultants and midwives take responsibility for dealing with serious adverse events.

Serious safety issues in Portlaoise

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