The safety of babies being delivered at Portiuncula Hospital in Ballinasloe continued to be at risk even after the detection of seven cases in which babies died or were seriously injured, according to newly released documents.
The Department of Health last month expressed concern about an “ongoing patient safety issue” relating to the care of babies who were starved of oxygen during labour in the Co Galway hospital, the documents show.
This followed an audit which showed continuing problems with deliveries in spite of corrective measures introduced after the seven problem births.
Four cases of concern, which have not previously been disclosed, were found in the audit of 22 random deliveries in December. The department said this showed the measures introduced earlier that month had not been fully implemented.
Arguments between the department and the HSE over the seriousness of the issues at Portiuncula contributed to a delay in informing the seven women of a review into their cases. There were also disagreements over the wording of public communications, according to the documents obtained from the department under the Freedom of Information Act.
Senior HSE managers disagreed about the seriousness of the problem births and resisted apologising to the families involved, the documents reveal.
Safety procedures
The records show Minister for Health
Leo Varadkar
, his officials and the head of the HSE remained in the dark about the problems for a month, despite previously agreed procedures for escalating serious incidents.
Mention of the four cases identified in December’s audit was taken out at a late stage from the press release issued last month, when news of the seven problem births leaked.
The seven original cases involved babies who were starved of oxygen during birth and were referred to Dublin for brain cooling treatment, designed to reduce the risk of brain injury. Two of the babies died. The deficiencies in care relate to the interpretation of tracings of the foetal heartbeat, the administration of drugs to accelerate labour and the use of forceps and other instruments in delivery.
The department also complained to HSE director of acute hospitals Dr Tony O’Connell that the original seven cases, “all involving death or serious injury in normally formed term infants”, were not brought to the attention of senior management, in line with procedures.
‘Significant concerns’
“The fact that concerns of this nature which have arisen in the context of significant existing concerns regarding safety of maternity services in small units were not escalated either to your office or the new national director for quality assurance and verification is a matter of particular concern.”
Dr O’Connell opposed apologising to the families or saying publicly the babies were harmed. “The alarm bells are ringing but nothing is definite,” he commented.
Another official said harm had not been established in all cases, to which Dr Tony Holohan, the department's chief medical officer, said: "Not wishing to be pedantic, but it cannot be said that harm did not occur".
The chronology shows HSE national director for patient safety Philip Crowley was informed on November 29th last about the review of the seven cases at Portiuncula. It wasn't until December 29th that HSE director general Tony O'Brien and Dr Holohan learned what was going on.
