HSE chief coy on actions
Asked if he had very serious questions to answer, he said the bulk of the “adverse events” that were the subject of the report happened before he became director general of the HSE and his job was to change the way the health authority operated.
One of the “quite difficult” choices he had to make at a central level was to divert resources away from services and into the acute hospitals to address some of the issues identified in the report. As far as he was concerned, he was acting correctly.
Asked if people would be held to account for what happened in Portlaoise Hospital, Mr O’Brien said management would take action “as appropriate” when they had carefully studied the report.
He said the HSE had “fundamentally” changed its approach to quality assurance and verification.
“We have a much more systematic approach which is specifically designed to ensure that any failings of the past are not repeated into the future.”
He again apologised to the families for the “very adverse experiences” they had in Portlaoise Hospital and said the HSE accepted the eight recommendations made by Health Information and Quality Authority (Hiqa).
However, he described as “a point of disagreement” a contention made by the that financial constraints could not be blamed for what happened in Portlaoise.
He thought it was wrong to overlook the very challenging, unique, and probably unprecedented circumstances that unfolded in the health service from the end of 2008 onwards.
Mr O’Brien was also asked about Roisín and Mark Molloy, whose son, also called Mark, died shortly after birth following complications in the hospital. The couple wrote to him in 2012 and he was aware they were unhappy with the way the quality and service division dealt with their concerns.
Mr O’Brien said the investigation had not reached a conclusion three years later because of issues arising from the reports on Port-laoise Hospital by the chief medical officer and Hiqa.
He knew the couple were unhappy with the way the investigation had proceeded which was why changes had been made since, Mr O’Brien said.
He said the open disclosure policy jointly developed by the HSE and the State Claims Agency was specifically designed to address the concerns of patients and families. “Open disclosure is clearly the right way to go. It has been talked about a lot in terms of recent events around X-rays and colonoscopies and so on. It is very much a part of the way we are doing business now.”
Mr O’Brien was also asked about Hiqa’s finding that the HSE was not a learning institution. There were opportunities to learn from various reviews that could have led to poor outcomes being prevented — babies may not have died.
Mr O’Brien said it was a serious finding but a “longitudinal” finding placed in the context of a series of Hiqa reports going back to 2007.
“I have said before that the HSE has been challenged in the area of translating lessons from one location to another. So, hands up, no argument about that.”
by Joe Leogue
The Hiqa report on the investigation into the safety, quality and standards of services provided by the Midland Regional Hospital, Portlaoise, includes a number of damning accounts by patients.
Here are extracts from the report detailing what these patients told the investigating team.
“The manner in which these parents [of deceased babies] received their babies was recounted by them as being grossly inappropriate and extremely traumatising. For example, they stated how their baby was brought to them in a metal box on a wheelchair covered with a sheet and pushed by mortuary staff. One mother described how the box was not of sufficient size and their baby was squeezed in to fit. She said she did not remove or hold her baby for fear of being unable to return him to the box.
“One woman said how she felt that staff avoided going into her room after her baby had died, while another woman said she was reprimanded for crying as it would upset other mothers who had delivered healthy babies.
“Some parents reported that they were told that their baby had been stillborn or that their baby had died instantly at birth.
“However, by obtaining documentation or reports after the birth of their baby, they subsequently discovered conflicting information about when their baby had died. This discrepancy in the facts surrounding the death of their baby was a source of great distress for these parents.
“One set of parents described being further traumatised when contacted by telephone years later with the query as to how they wished the disposal of their baby’s retained tissue to be carried out. They said informed consent had not been given by them to retain the tissue, or stated that they had no knowledge of any such retention.
“The Investigation Team met a woman whose reported experiences reflected a lack of compassion, humanity, dignity and respect during her care. Another woman recounted that some staff made her feel like a naughty child or that she was a troublemaker when she questioned her care and treatment.
“Another believed she was made to feel guilty for her tragic outcome and consequently this made her fearful of conceiving again. This fear of further pregnancy was a recurring theme among those parents who met with the Investigation Team.”
The Health Information and Quality Authority has made eight recommendations arising from its investigation into Portlaoise Hospital.
- 1. The Department of Health should commence discussions with the HSE to establish an independent patient advocacy service, with a view to having a service in place by May 2016. Its role would be to ensure patients’ reported experiences are recorded, listened to, and learned from.
- 2.The Department of Health should ensure implementation of the recommendations contained in this investigation report and previous investigations by the authority.
- 3.The Department of Health must develop a national maternity services strategy for Ireland, and should provide regular updates on its website to inform the public of progress with developing and implementing this strategy.
- 4. The Department of Health should expedite the necessary legal framework to enable the independent group boards of management and chief executive officers of each hospital group to comprehensively perform their governance and assurance functions.
- 5. The HSE should ensure the appointment of a director of midwifery, before September 2015, in all statutory and voluntary maternity units and hospitals in the country that currently do not have such a post.
- 6. The HSE, along with the chiefs executive of each hospital group, must ensure that the new hospital groups prioritise the development of strong clinical networks.
- 7. The HSE, in conjunction with the chief executive of the Dublin Midlands Hospital Group, should review all of the findings of this investigation and address the patient safety concerns at the Midland Regional Hospital, Portlaoise; immediately address the local clinical and corporate governance deficiencies in the maternity and general acute services in Portlaoise; publish an action plan outlining the measures and timelines to address the safety concerns and risks at Portlaoise; ensure that every hospital undertakes a self-assessment against the findings and recommendations of the investigation report; and develop, implement, and publish an action plan to ensure the quality and safety of patient services.
- 8. The HSE, hospital group CEOs, and State Claims Agency must develop, agree, and implement a memorandum of understanding between each party to ensure timely sharing of actual and potential clinical risk information, analysis, and trending data. The information must be used to inform patient safety strategies.
Before the Health Service Executive assumes the management of the health system, the Midland Health Board’s final service plan warns of pressure on its maternity services due to an increasing birth rate and says that the region’s rising population is a key issue for the year ahead.
A review is published into midwifery staffing at Portlaoise Hospital, initiated by the hospital’s director of nursing and the Dublin Mid Leinster region’s director of nursing planning and development unit. It makes a number of recommendations, including the development of a maternity assessment unit and tackling the high rate of staff absenteeism.
While a maternity assessment unit was established by the end of 2007, concerns raised regarding midwifery leadership and the need for midwife shift leaders were not fully addressed until eight years later, after media and political attention focused on the services following serious adverse events in 2014.
Staff at Portlaoise Hospital express a number of serious concerns about the quality and safety of breast disease services in the hospital to the director of nursing. These concerns were brought to the attention of the HSE regional network manager in August 2007 and a decision to suspend breast radiology services at the hospital was made.
The HSE publishes two clinical reviews of the mammography and ultrasound services at Portlaoise. Mammograms and ultrasounds of patients who had received treatment at the hospital between August 2005 and August 2007 were reviewed. The review concluded that best practice in breast imaging services was not adhered to at Portlaoise Hospital.
A Hiqa report into Ennis hospital is published. It found a risk associated with treating low numbers of acutely ill patients in smaller, standalone hospitals without senior clinicians being on site 24 hours a day. The report advised that the HSE should universally apply the recommendations to similar-sized hospitals, including Portlaoise.
Hiqa publishes a report into Mallow hospital. Again, like the Ennis report, its findings are applicable to Portlaoise. It warns of the potential risks to acutely ill patients in hospitals that did not have a clearly defined model of service outlining what could and what could not be safely provided to patients.
Hiqa finds that Portlaoise hospital has inadequate corporate and clinical governance arrangements which contribute to serious risks to patient safety. By this year Hiqa has received seven pieces of unsolicited information regarding individual patients’ experiences of their care across a number of services including maternity, acute, and emergency services, and hygiene practice at Portlaoise Hospital.
The authority’s Tallaght Report makes further recommendations regarding the provision of emergency services nationally..
Following the Ennis and Mallow reports, the Department of Health and HSE publish the smaller hospitals framework, a plan and model of care for the provision of services at smaller acute hospitals throughout Ireland. National recommendations are made from Hiqa’s 2013 report and the Chief Medical Officer’s February 2014 report on the death of Savita Halappanavar in Galway in October, 2012.
