Women who suffer adverse events in Irish maternity units should be provided with the results of a review into their case within two months, a new report has recommended.
Every hospital should have a formal system for auditing pregnancy outcomes on a monthly basis, according to the review commissioned by the Health Service Executive.
The review chaired by Dr Peter Boylan, former master of the National Maternity Hospital, looked at the case notes of 28 births about which concerns have been raised, and identified 10 where further issues need to be addressed. Six of these involved a stillborn or neonatal death.
It says a formal, regular auditing system would allow a pattern of adverse outcomes to be identified in a timely fashion, so that appropriate action could be taken.
Each hospital should have in place a formal system of review of adverse outcomes and the results of the reviews should be shared with the patients in a timely fashion. While recommending this should happen within two months, it says this deadline is subject to legal and other issues that could arise.
Portlaoise hospital
Most of the cases relate to the Midland Regional Hospital in Portlaoise and cover the period 1985 to 2013. The review was established in response to concerns raised by women in the aftermath of revelations last year about baby deaths in Portlaoise hospital. The families concerns have been given individual reports but these are not being published for reasons of privacy and confidentiality.
Other recommendations in the report are that each hospital should ensure the appointment of a number of midwives trained in ultrasoundography and hospitals should appoint bereavement counsellors to deal with perinatal deaths.
The report says that each hospital should have adequate midwifery and consultant obstetrician staffing and ongoing mandatory training programmes for all clinical staff.
It says that in the event of a perinatal death, every effort should be made to gain consent for a post-mortem examination.
The report recommends the appointment of midwives trained in ultrasonography in each hospital, as well as bereavement counsellors to deal with perinatal deaths.
Hospitals should have adequate midwifery and consultant obstetrician staffing and ongoing mandatory training programmes for all clinical staff.
In the event of a perinatal death, every effort should be made to gain consent for a post-mortem examination.
The Institute of Obstetricians, which is chaired by Dr Boylan, called for the full implementation of the recommendations.
Prof Boylan expressed his sympathies to the families who have suffered and who consented to having their case notes reviewed. “I wish to acknowledge the grief of these parents and to sympathise with them,” he said.
The women whose cases have been reviewed have been advised to contact the Dublin Midlands Hospital Group to ensure their concerns have been addressed. Counselling support is also being provided.
Further to Dr Boylan’s review, a further 103 cases are being examined by the hospitals involved. Of these, 94 relate to Portlaoise, while the other nine involve other hospitals.
