Senior officials in the HSE failed to visit Portlaoise hospital to assess safety concerns after last year's RTÉ Prime Time programme on baby deaths in its maternity unit, the draft Hiqa report claims.
There was no evidence key senior HSE executives who had ultimate responsibility for health service delivery visited the hospital to assess the situation on the ground in the immediate aftermath of the programme, according to the report. This was “of significant concern” to the investigation team.
There was no evidence to confirm “worthwhile discussions” had taken place at HSE directorate or leadership levels in relation to the experiences of people who used the maternity unit in the hospital, it says.
The report says it was evident throughout interviews with national HSE managers that up to the latter part of 2014, they were “predominantly focused” on budgetary austerity and the Government “imperative” to control healthcare spending. This included an emphasis on reducing staff numbers in the health service.
No meaningful oversight
Before chief medical officer Dr Tony Holohan published his report into the baby deaths at Portlaoise in February 2014, there was no evidence to show that at a national level, meaningful oversight of the hospital was maintained.
“Sadly, the experience of many people using the maternity services at the hospital who met with the investigation team reinforced these findings.”
The investigation team expected to find that patient safety was at the top of the HSE’s executive management agenda, that it would be a standing item at all meetings, and that senior HSE staff were aware of what was happening in Portlaoise hospital, the report states. “However, the evidence reviewed . . . indicates that this was not the case.”
The report says senior regional managers told investigators the most serious risks at the hospital were its emergency department, access to 24-hour CT scanning and difficulties in recruiting staff.
However, most local managers identified the rising birth rate, deficiencies in midwife staffing and financial management as the most serious risks.
‘Overwhelming evidence’
In the context of a performance forum convened within the Dublin Midlands Hospital Group, and despite “overwhelming evidence” to suggest the management team in Portlaoise was struggling, there was no evidence to show regional HSE managers stepped in and took control of the situation.
The investigation team could not find any evidence that any form of decisive action occurred or was even considered in the aftermath of the Prime Time programme.
Although HSE regional management staff were aware of risk management deficits in the hospital, a passive approach to managing risk was taken.
“The authority is deeply concerned that this was allowed to happen and that such inert governance arrangements prevailed.
“The investigation team was consistently informed that – with the exception of the clinical director – there was poor visibility of the hospital management team at ward level. The hospital management team did not routinely visit patients care areas and did not conduct safety walk-arounds.”
Incorporating Portlaoise into a hospital group structure, with doctors and speciality nurses being obliged to rotate between sites as required - is the only way to assure the provision of a “clinically competent and stable workforce” at the hospital, according to the report.
About 1,338 incidents relating to treatment, slips and falls were reported at the hospital from June 2013 to March 2014, but only four quality improvement initiatives were submitted, it notes. * 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.”
