Significant concerns over the quality and safety of maternity services at Midland Regional Hospital in Portlaoise existed as far back as 2007 but were not acted upon, according to the draft report from the State’s health watchdog.
Regional HSE staff failed to act on the concerns expressed by senior officials of the Clinical Indemnity Scheme, while national staff remained unaware of them, the report by the Health Information and Quality Authority (Hiqa) says.
The scheme, run by the State Claims Agency to handle medical negligence cases, offered to commission an independent obstetric expert to review the maternity services, according to the report.
However, senior regional HSE staff declined the offer, saying they were addressing the issues.
Hiqa says it is of significant concern that seven years before last year's Department of Health report into baby deaths in Portlaoise, the scheme was aware of the risks in maternity services and that the HSE and the scheme did not have systems in place to share and use this information to address these concerns.
It says it was not surprised when senior HSE managers told its investigators they were "not aware" of any safety concerns or staffing issues in relation to the hospital before last year's Prime Time programme into the baby deaths.
“Some senior HSE staff explained that there would never have been an issue or delay in recruiting staff had they been told that there had been a problem.”
Hiqa says some senior HSE staff told its investigators they did not know of the cases identified on Prime Time . No serious incidents were reported by the hospital and they only became aware of the cases through a patient advocacy group.
‘Not surprising’
“Even more worryingly, one senior HSE staff member told the Hiqa investigation team that these circumstances were not surprising and will very likely reoccur elsewhere.”
The report says it is evident from the cases featured on Prime Time that the HSE mechanisms for reporting adverse events did not work in those particular cases. "The current process, often protracted, leaves families with unanswered questions pending the publication of a final report, thereby increasing their upset and trauma."
It can also mean underlying quality and safety issues may remain unidentified and unresolved for lengthy periods.
Hiqa says these delays are not specific to families attending Portlaoise hospital.
Until the Department published its report last year, senior HSE staff simply did not proactively address the inherent risks identified in the hospital.
“It is now imperative that the HSE recognises that devolution of the responsibility for quality and patient safety to those charged with the delivery of care is not a substitute for senior managers within the HSE maintaining adequate oversight of this key aspect of the service that they preside over.”
* The Irish Times put a number of specific queries about Portlaoise hospital and the draft Hiqa report to the HSE.
The HSE responded to these queries saying it was disappointed with the contents being leaked and that some of the adverse findings were “inaccurate”.
It said:
“It is very disappointing to read the contents of a draft report which have been leaked by Hiqa to the media at a point when some of those central to the findings of the report have not yet been notified by Hiqa, have not been informed of the adverse findings, and have not had an opportunity to respond appropriately.
“The HSE is on record as stating that the report contains inaccuracies, and lacks context and balance. Indeed, some of the adverse findings reported in the media today [Tuesday 7th April] are inaccurate and should not appear in the
final report.
“It is clear that a decision to leak the report at this time is an attempt to publish certain findings before there has been an opportunity for the HSE to respond appropriately and for inaccuracies to be corrected and removed from the final report.
“It is most unfortunate that certain individuals will have sight of adverse findings pertaining to them for the first time in the media.
“This is highly irregular and in direct conflict with an individual’s Constitutional rights to due process and fair procedures.”
In repsonse to this HIQA said: "Hiqa continues to finalise this investigation report, the due process in respect of the draft report is ongoing and the Investigation report has yet to be finalised and submitted to the Board of Hiqa for its consideration and approval.
“Any suggestion that Hiqa has leaked any investigation report is totally false and untrue.
“Hiqa’s conduct of this investigation is in line with all previous investigations and reviews guided by the principles of fairness and objectivity.”
