An independent patient safety service should be established within a year to ensure patients' experiences are learned from, according to the Health Information and Quality Authority report on Portlaoise Hospital.
Managers at all levels in the HSE - local, regional and national - were aware of patient safety risks at Portlaoise hospital but failed to act on them, the report has found.
The report, commissioned following the deaths of five babies in the hospital’s maternity unit, says the HSE and the hospital failed to learn from the recommendations made in previous reports.
Hiqa chief executive Phelim Quinn said the report shone a light on what happened in the hospital and described it as a “seminal moment” in the history of the health service.
“It is notable that local and national HSE inquiries and clinical reviews into patient safety incidents and significant service failures in Portlaoise Hospital were also carried out. Had the findings and recommendations of these inquiries and reviews been attended to, the risks to patient safety and service quality could have been substantially reduced.”
Lack of urgency
It criticises passivity among managers as well as a “widespread lack of urgency” to respond to risks, and claimed the hospital was “beset by indecision” despite numerous recommendations for change over the years. The 200-page report is implicitly critical of the Government for failing to properly fund the level of services provided in the hospital, including 24-hour emergency care.
The report is largely unchanged from an earlier draft which was heavily criticised by HSE director general Tony O’Brien, who at one point threatened to take legal proceedings to prevent its publication. Mr O’Brien claimed the draft report was inaccurate, lacked context and did not give those criticised an opportunity to respond.
The HSE is expected to rebut the criticisms made by Hiqa when it holds its own press conference later this morning. It is likely to emphasise its contention that the hospital is now safe, following governance and staffing changes made over the past year, as well as highlighting what it believes are inaccuracies and unfair aspects in the report.
While it has not carried out its threat to injunct the report, a legal challenge aimed at having it quashed is still a possibility.
Treatment of women
Margaret Murphy, a patient representative and member of the Hiqa investigation team, criticised the treatment of the women who lost their babies.
She described how bereaved mothers were reprimaned for crying, and how one deceased baby was brought to its mother on a tin box on a wheelchair.
She said women were wrongly given the impression their babies’ deaths were isolated incidents and were met with “defensiveness, cover up and unfulfilled assurances”.
“To err is human, to cover up is unforgivable, to refuse to learn is inexcusable,” she commented.
HSE response
The HSE said that, as things stand today, it is satisfied that maternity services at Portloaise hospital are “very safe”.
At a press conference held shortly after the publication of the Hiqa report, the HSE said it was committed to the recommendations made on services at the hospital.
Mr O’Brien apologised to the affected families but said he would not be stepping down on foot of the findings of the report.
He said, that following an earlier investigation by the Chief Medical Officer that “effective, swift and decisive” action had been taken at the hospital and said the HSE had “no agenda to downgrade Portlaoise hospital”.
Dr Susanne O’Reilly, chief executive of the Dublin Midlands Hospital Group said that, as things stand today she was “satisfied that maternity services at the hospital are safe”.
She said a number of appointments had taken place at the hospital including the appointment of 16 midwifery places and the replacement of 20 agency nursing posts by permanent staff while others were in train.
