Oireachtas Joint and Select Committees
Thursday, 6 March 2014
Joint Oireachtas Committee on Health and Children
Report on Perinatal Deaths at Midland Regional Hospital: Discussion
I welcome everybody to the meeting and remind everyone that mobile phones should be turned off or left in flight mode as they interfere with the broadcasting of proceedings. I welcome viewers on UPC channel 207.
We have received apologies from Deputies Ciara Conway, Regina Doherty and Mary Mitchell O'Connor and Senator Jillian van Turnhout. Deputy Sandra McLellan will be here soon.
I welcome the Minister for Health, Deputy James Reilly; Dr. Tony Holohan, chief medical officer; and from the HSE Ms Laverne McGuinness, Ms Kathleen MacLellan, Mr. Ian Carter and Mr. David Walsh. I thank all of them for attending. The purpose of the meeting is to hear from the Minister and the chief medical officer in the light of the report on perinatal deaths at the Midland Regional Hospital, Portlaoise. The committee has been concerned about this issue and we agree that the revelations in the report are shocking. The report which was commissioned by the Minister and carried out by Dr. Holohan has many sobering statistics and interesting observations to make. I hope all committee members will join me in congratulating the families on their bravery, in sympathising with them on their loss and hoping the report will in some way allow for a new and better day for many families as a result of what will happen not just in this hospital but others also.
Witnesses are protected by absolute privilege in respect of their evidence to the committee. However, if they are directed by it to cease giving evidence on a particular matter and continue to do so, they are entitled thereafter only to qualified privilege in respect of their evidence. They are directed that only evidence connected with the subject matter of these proceedings is to be given and asked to respect the parliamentary practice to the effect that, where possible, they should not comment on, criticise or make charges against a person or an entity by name or in such a way as to make him, her or it identifiable. Members are reminded of the long-standing ruling of the Chair to the effect that they should not comment on, criticise or make charges against a person outside the Houses or an official by name or in such a way as to make him or her identifiable.
I call on the Minister to make his opening remarks.
I thank the Chairman and committee members for giving me this opportunity to speak to them. I will keep my introductory statement as brief as possible and will be happy to reply to comments and questions. As the Chairman pointed out, we are joined by the chief medical officer, Dr. Tony Holohan, and the chief of the clinical effectiveness unit, Ms Kathleen MacLellan, not to mention our other friends from the HSE, Ms Laverne McGuinness, Mr. Ian Carter and Mr. David Walsh.
I reiterate my thanks, as the Chairman has done, to the families concerned who, in the face of their individual tragedies, had the courage and tenacity to ensure their babies’ stories were heard. I assure them that we have listened and learned and are fully committed to embedding that learning in all health services. Families and patients at Portlaoise hospital maternity services, PHMS, were not treated with an acceptable level of care, compassion and respect. I was so distressed by the experiences of the families I had met that I immediately requested the chief medical officer to conduct a review of safety at PHMS. This review was completed in three weeks and highlighted some critical issues for the health service.
The chief medical officer’s report is far-reaching. It makes 11 overall and 42 specific recommendations, all of which I have accepted. It not only sets out the immediate requirements for assuring safety for women attending PHMS but it also provides the strategic direction for maternity services in Ireland generally. Clear failures were identified in this preliminary risk and patient safety assessment of PHMS. This conclusion is drawn from Portlaoise hospital’s own assessment of its risk management processes; current risk management arrangements in place; monitoring of the implementation of recommendations in various investigations of adverse events in Portlaoise hospital; and findings made by the chief medical officer regarding patient safety and care. These failures were at both local and national level.
The critical initial question which the report addresses is whether the service provided by PHMS can be considered safe now and into the future, given the events reported in public and Portlaoise hospital’s response to them. I understand the significance of these patient safety failures and I am clear about the next steps that need to be taken. I have decided on a twin-track approach, providing specific directions and requests for both HIQA and the HSE. In addition, I will be requiring a number of assurances from my Department.
I reiterate a statement that I made to the families and the public last Friday. Portlaoise hospital maternity services could not be regarded as safe and sustainable within the existing governance arrangements, as they lacked many of the important criteria required to deliver, on a stand-alone basis, a safe and sustainable maternity service. On this basis and with immediate effect, I requested the HSE last Friday, 28 February, to put in place a transition team to assume control of the maternity service at Portlaoise hospital. This team, consisting of appropriate clinical and managerial expertise, will oversee the planning and execution of an orderly integration of PHMS within a managed clinical network under a singular governance model with Coombe Women and Infant University Hospital.
The HSE responded to my request immediately and a new general manager and director of midwifery were appointed to the hospital the same day. This interim management team will remain in place until a new governance arrangement is put in place for PHMS. Dialogue has also commenced with the Coombe Women and Infant University Hospital about how best to provide support to PHMS in a collaborative working arrangement into the future. I met some members of the board yesterday. Furthermore, I have requested the HSE to conduct a review of PHMS in respect of services for the infant and the family following a perinatal death.
The HSE must ensure effective systems are in place, including the provision of training where necessary, to ensure senior clinicians are competent to take responsibility for dealing with serious adverse events when they occur, including dealing appropriately with patients in such circumstances. The chief medical officer’s findings cannot be restricted to the maternity services at Portlaoise hospital; there are also ramifications for other services at the hospital and, to this end, I have requested the HSE to address the implications of this report for these services. In addition, I have asked that the HSE also look at other similar sized maternity services around the country and consider their incorporation into managed clinical networks within their relevant hospital group.
The HSE is about to commence a midwifery workload and workforce review in maternity services in Ireland. This project has been jointly commissioned by the HSE office of nursing and midwifery services director and the joint standing maternity committee of the Dublin maternity hospitals with the approval of the director of the HSE’s obstetrics and gynaecology programme, national director clinical strategy and programmes division, national director of quality and patient safety and the support of the chief nursing officer in the Department of Health.
The failures identified in this report were at both local and national level. I am acutely conscious that there is enormous pressure on the staff of the PHMS and of the need to rebuild their morale and confidence so that they can rise to the challenge of providing a safe and quality service. I have, therefore, requested the HSE to provide support to the Portlaoise hospital senior management team. This should lead to a wider programme of support for front-line leaders, particularly in smaller hospitals, to ensure they can, and do, provide safe and effective care. I want the HSE to ensure, in the first instance, every maternity service, and, thereafter, every health care service provider, is required to complete a patient safety statement, which is published and updated monthly. The statement will include information such as birth rates, adverse events and others and should be a requirement of hospital licensing.
However, this is not enough. I consider that a thorough investigation is required and in accordance with section 9(2) of the Health Act 2007, I have directed HIQA to undertake an immediate investigation of PHMS and to report to me by the end of 2014. I anticipate that many of the as yet unanswered questions will be addressed in the course of the HIQA investigation.
A culture of quality and of safe care is one in which there is open, kind, transparent, compassionate and sensitive care, effective team communications and a commitment to prevention of harm. A positive patient safety culture is focused on enhancing every aspect of the experience of a patient. It is well established in evidence that culture and behaviour are critical components of safe and effective care. To this end, I have requested that HIQA should also conduct an immediate assessment of the patient safety culture at Portlaoise hospital. I have also requested HIQA to adopt a standard tool for the assessment of patient safety culture and team working and to use its independent monitoring role to ensure it is implemented throughout the health care system.
In addition, I have asked HIQA to develop national standards for the conduct of reviews of adverse incidents. In this context, I have also requested that the HSE should issue a directive to all providers to require them to notify the director of quality and patient safety and HIQA of all "never events". In this case "never events" will include perinatal deaths from low risk pregnancies. A "never event" by its nature cannot always be prevented, but the very fact that it happens should mean an urgent examination by the hospital in question of all its systems. My Department will, through the forthcoming health information Bill, make the notification of "never events" a mandatory requirement.
An outline of the patient safety risk profile of hospitals in general and for PHMS specifically was not available in the preparation of this report. The requirement to pool information that may exist across agencies to create better risk and safety profiling of services is a critical gap in our patient safety functions nationally. To this end, I have recommended the establishment of a national patient safety surveillance system by HIQA. HIQA will use this information for risk stratification and guiding the targeting of their standards monitoring programme. My Department will examine any amendments to the Health Act 2007 that may be required.
A broader finding identified in this report was the systematic under-reporting of perinatal deaths due to inconsistencies in Ireland's perinatal data collection. Specifically, this requires a single definition of a perinatal death for the Irish system. This will require changes to the Civil Registration Act 2004 and in this regard, my Department will work closely with the Department of Social Protection to ensure that all official perinatal mortality rates are calculated using a common definition. I have asked my Department to immediately actively pursue all actions identified for it in this report. I will require regular patient safety assurance reports from both the HSE and HIQA to inform me of the progress on the implementation of all recommendations in this and all other reports. I will not tolerate any delays in progressing the critical patient safety issues that have been identified.
The report into perinatal deaths at the Midland Regional Hospital Portlaoise is far reaching. It not only sets out the immediate requirements for assuring safety for women attending PHMS but also provides strategic direction for maternity services in Ireland generally. The report will not only inform, but underpin the planned development of a national maternity service strategy which will be delivered this year. This strategy will provide the strategic direction for the optimal development of our maternity services to ensure all women have access to safe, high quality maternity care in a setting most appropriate to their needs and it is my intention to publish the strategy this year. We need to learn from past mistakes and move on to rebuild confidence in the safety of our maternity services. The new strategy will determine the future model of our maternity services to ensure they are fit for purpose and in accordance with best available national and international evidence.
The report shows that the planned patient safety agency, PSA, has a vital place in our health service, which is why it is included in this year’s HSE service plan. The agency will be established shortly and applications for a chief executive officer will be invited. The PSA will be a "patients’ champion" supporting patients to ensure they receive an appropriate response to the safety issues they raise. The PSA will also promote and disseminate learning on how we can build and enhance a safety culture in all our health care services.
As Minister, I am acutely conscious of the importance of patient safety. The stories of babies Katelyn Keenan, Joshua Keyes-Cornally, Mark Molloy and Nathan Molyneaux made a significant impression on me and I am sure everybody present. I would like once again thank their parents Sharon, Thomas, Natasha, Shauna, Joey, Roisin and Mark who brought the serious failures identified in this report to light. I listened to the parents when they said they wanted their local services to be safe and I assure them and other parents that the Department, HSE and I will do everything within my remit as Minister to ensure every step is taken to prevent such events occurring in the future.
I will hand over to Dr. Tony Holohan, chief medical officer of my Department who will give a brief presentation and overview of the report he prepared on the perinatal deaths at Midland Regional Hospital Portlaoise. I would like to express my thanks to the Chairman and the committee members for listening.
I call Dr. Holohan. I apologise to members because the screens for the PowerPoint presentation are not working. It is a pity because Dr. Holohan has taken time to prepare a thorough presentation. However, members have been circulated with a hard copy.
Dr. Tony Holohan:
I thank the committee for the opportunity to address it. The Minister has covered some of the ground and, therefore, I will try to be as brief as I can. The report is set out in a number of sections and it is not available on the Department's website. I have one or two hard copies but I believe copies have been distributed to members.
The report outlines the background, the methodology we used, describes the Midland Regional Hospital, Portlaoise, maternity service and sets out our analysis under two headings: first, quantitative findings which are set out in section 4; and, second, qualitative findings which are set out under seven themes in section 5. It then sets out some overall conclusions and recommendations. There are 42 recommendations throughout the report regarding the section 4 quantitative findings and the section 5 qualitative findings. They are summarised in a sense by the 11 overall recommendations. It is important that all of the recommendations be taken together. We are all aware of the context.
Moving on to the section on methodology, the key question we set for ourselves to try to address and the one which was on everybody's lips was: was the service safe? While we could not answer that question in an absolute sense, we set out to examine the extent to which there was verifiable implementation of the recommendations from the investigations the hospital had conducted into its own declared incidents over a number of years and other relevant national policies. The further along we could say it was in verifiable implementation of these matters, the more satisfied we could be about safety on a continuing basis. That was the approach we took.
We had meetings with a number of organisations as set out in detail in the report in one of the tables in the section on methodology. We met a number of national organisations, including the Medical Council, HIQA, the State Claims Agency and An Bord Altranais. We met representatives of a number of sections within the HSE. In particular, we met representatives of the Midland Regional Hospital, Portlaoise, on three separate occasions, over eight to nine hours in total. We were facilitated significantly by Mr. David Walsh who is present. If it were not for his involvement, we would not have been able to gain access to the information and the response as quickly as we were. We would not have had the report as quickly.
We requested a considerable amount of data from the hospital to give us the basis for some of what we set out in the report. We received all of it in a timely fashion. We also made an examination of national perinatal mortality reporting systems and took a walk around the Midland Regional Hospital, Portlaoise, which I had never seen previously. I will not spend too long describing the services at the hospital, as I imagine members are quite familiar with it and its services. It is a three-consultant service. It is not a training location for the SPR programme in obstetrics and gynaecology or for midwives. It has an agency dependency level of 25% for both medical and nursing staff and, as I will cover, a high vacancy rate, particularly in leadership positions for midwifery.
The slide on section 4 presents national birth numbers. They show a significant increase in national birth numbers between 2000 and the present, in particular between 2000 and 2007. During that time period there was an increase of approximately 30% in the total number of births. It was particularly acute in a two year period when it increased by 17% nationally. The picture in Portlaoise is quite different, with a much more significant increase in the total number of births. In the seven years to 2007, the hospital experienced an increase of approximately 100% in the total number of births, with 50% of that increase occurring in a two year period between 2005 and 2007. That is an interesting and relevant finding.
The next slide shows some of the analytical work we did on the numbers of perinatal deaths at the Midland Regional Hospital, Portlaoise, as derived from its own direct account, from what the national perinatal reporting system states about it and from what the National Perinatal Epidemiology Centre system states about it. Let me take one minute to explain. There are a number of reporting and data collection systems relating to perinatal events, both mortality and morbidity. We have the national perinatal reporting system which was compiled, managed and reported on by the ESRI until the recent health reform changes resulted in that function moving from the ESRI to the HSE. Another is the relatively recently established National Perinatal Epidemiology Centre under the direction of Professor Richard Greene in Cork which gathers its data directly from the individual hospitals and makes reports on both maternal mortality and morbidity rates. We have the General Register Office under the auspices of the Department of Social Protection and the CSO that makes reports in the form of vital statistics. Between each of these systems we see some inconsistencies in reporting and some systematic errors in reporting such that we believe there is an under-reporting of total perinatal mortality rates. It is not sufficiently significant to change our overall ranking on an international basis in terms of how we fare relative to other countries, but it is significant in so far as we believe the correct and absolute measure, the one set out in blue on the slide, would the highest. That is the one we believe would be the best and the one to which the report recommends moving towards.
We are recommending that each national reporting system reports on essentially the same definition. That will require changes to the existing definitions set out in the Civil Registration Act and we are in discussions with the Department of Social Protection on the matter. It will also require some consolidation of both the NPEC in Cork and the NPRS that has come into the HSE from the ESRI. They are two broadly similar systems, collecting similar data and reporting differently. There is room, not just from the point of view of commonality of reporting but also from the point of view of avoiding duplication and the obvious difficulty that arises when two systems give two slightly different answers to the same question. It also reduces the workload for staff on the ground having to report to different systems. Therefore, we have made specific recommendations in that regard.
On the available data we sought and received from the hospital, the next slide shows the numbers of transfers per 1,000 births. These data given to us from the hospital show both paediatric, that is, neonatal, and maternal transfers to other centres, mostly in the Dublin region in the perinatal period. We can see the number increased significantly over time. The increase is not explained by the number of births because these figures are per 1,000 births. That is a relevant finding.
The next slide shows information we received from the hospital on adverse incident reports. Members may be aware that the State Claims Agency requires that each adverse incident that occurs in the health service be reported to it and it compiles and collates the data. We sought all reports from 2006 reported by the hospital. We have set out a graph showing that, overall, it follows the same trend that we can see regarding transfers. Something unusual and different was happening in 2007, which explains that peak and I am happy to talk about it during members' questions, if they so wish.
Figure 4.6 on the same slide shows the number of claims per 1,000 births for the Midland Regional Hospital, Portlaoise, as compared with the average for six similarly sized units in the country. We can see that over the period of time there was a higher number of claims. Overall, the number of claims is not very large - one would not necessarily expect it to be, but there is a significant difference between the two. There would be a lag time in the reporting because of the nature of claims and when they are submitted. That might explain some of the tail-off shown in the graph.
The other thing which is not set out in the slide on which we have reported in the report in the area of quantitative data is the concept the Minister mentioned of "never events". There is a listing which is contained in our forthcoming health information Bill - it is the subject of a recommendation in the report. We know that six such events took place over the time period, four of which related to deaths or significant perinatal injuries that resulted ultimately in the deaths of babies who were essentially normally formed in low-risk pregnancies. There were two others that related to retention of foreign bodies following surgical procedures in that unit over the time period. This is set out in the report. The nature of what is a "never event" and the discipline of patient safety internationally suggests each of these events needs to be treated as though it should not have happened. It is the opportunity to stop and re-examine all procedures to ensure it never happens again.
The qualitative findings are set out in some detail in the report and we have organised them under seven themes, the first of which we deal with is that of patient-centredness. We dealt first with the culture at the hospital. We talked to the families at some length. We met them on a number of occasions through the conduct of this work, as well as at the beginning, with the Minister. Their powerful testimony of their treatment - the things said to them, the behaviour of staff, the interaction of staff with them and each other - and some of the things we heard from staff give us considerable cause for concern about the nature of the culture in the unit.
Members will see much in the literature about the importance of culture in health services and its ability to shape the safety of the service people are receiving. There are ways in which culture can be measured and there are tools that can be used to assess it.
It is important for services to be aware of the culture from a patient safety point of view as it has a big impact on the quality and safety of the service people receive. We have made a specific recommendation, as the Minister stated, on the need for HIQA to conduct an assessment of the culture in the remainder of the hospital. Some of the services dealing with perinatal deaths, in other words, dealing with the family after a death had occurred and dealing with the infant who had died, fell very far short of a reasonable standard of care. This was down to issues as important as the ability to hold or interact with infants after they had died to dress and wash them. This added significantly to the grief of the families and their inability to reach a point of closure on what had happened. Some of this was among the most harrowing evidence we heard about the service.
With regard to the response to patients and families following adverse events, without going on at length about it, we see this as an opportunity for senior clinicians and nursing staff to step up and take additional responsibility in circumstances where something unforeseeable has gone wrong. In these situations families were left significantly on their own in the hands of risk managers not involved in clinical care for the purpose of conducting investigations. Families had questions which were not addressed or answered. At the very moment when senior staff were needed most they were absent in some of the incidents.
With regard to open disclosure, we know from the original programme aired that a number of families were not, even until the programme aired, told about significant adverse events they or their babies had experienced. This is not consistent with the HSE's open disclosure policy, to say the very least. We have examined the HSE's open disclosure policy through the lens of what we have seen and it is a very good policy which stands up. The issue is to ensure it is appropriately and consistently implemented.
Clinical governance describes the arrangements in place for risk management, identifying adverse incidents and appropriately investigating them. Suffice it to say, the extent to which good risk management and adverse incident investigation practices were applied was highly variable. The quality of incident reports completed was highly variable. In some cases, the investigation of incidents did not start until a significant period of time after the incident had taken place, which creates a challenge in making findings on the basis that staff would not clearly remember what had happened. We make recommendations on the need to develop national standards and for HIQA to have national standards for the conduct of investigations. Desktop reviews or more significant investigations differ in their purpose and the period of time within which they must be completed. These will be the subject of the standards we recommend.
The systems in place to provide proper verifiable assurance on the implementation of the recommendations contained in the reports were weak. We believe this explains why many of the same recommendations came up in the hospital's reports without any audit-type information to examine the extent to which they had been implemented. Issues and themes which are set out in the report came up as explaining recurring events and this suggests a weakness in the arrangements and procedures.
Clinical effectiveness relates to clinical guidelines, clinical standards and audit arrangements. Following the HIQA report on the death of Savita Halappanavar, work has started on clinical practice guidance on clinical handovers and the escalation of care to complement much of what has already happened with regard to early warning scores for maternity services and adult and paediatric services. We have made an additional recommendation arising from the recurrence of concerns about the use of oxytocin in the hospital's investigations. We have not second-guessed this finding. We need a national standard on the induction of labour which may include a protocol on the use of oxytocin.
With regard to the escalation of incidents and the role of the HSE, we reflected on the system put in place following what had happened in Portlaoise in 2007. A significant number of missed breast cancer diagnoses had been uncovered as a result of an investigation at the time. The system enabled reporting to take place from local to national level, but this requires the local level to realise there was a difficulty. Other than one individual case, we have not been able to find any other escalation of incidents. The hospital did not know it had a difficulty. This is a passive system of reporting. Beyond this, it appears no other system has been in place since 2007 to detect problems or monitor the extent to which there are ongoing difficulties in the unit.
A number of specific recommendations are made on leadership, staffing and workforce planning. The importance of leadership is recognised from a clinical and midwifery point of view in the delivery of a safe and sustainable service. There are a number of leadership positions in the midwifery unit, the most senior of which is the CNM3 post, a clinical nurse management post, which was approved in 2007 and has never been filled. A CNM2 post has also been vacant for a period of time due to long-standing sick leave and of seven shift leader positions, clinical supervisory positions in midwifery, only one is filled on a permanent basis. This leads us to conclude the officer corps of the midwifery service was largely missing during the time period. This is relevant in the context of some of the hospital's own reports which identified difficulties with clinical supervision during the time period.
We examined a number of issues with regard to infrastructure and equipment. We examined the capital facility, in which we are not experts by any stretch, and identified a challenge posed by the fact that the operating theatre and labour ward are on different floors. This is particularly the case in situations where significant foetal distress requires an emergency Caesarean section. It requires the unit to have arrangements in place to practise evacuation procedures to ensure patients are brought to the operating theatre in a short period of time. It requires teams to put in place arrangements to practise these evacuations. This evacuation is not subject to practise but should be, given the infrastructural deficit.
Another dimension is hospital records. We have made recommendations to ensure implementation of the HSE's national chart and maternity record arrangements.
We heard much about medical devices from families, in particular about deficiencies as they saw them in the way in which equipment was used or the response to alarms on individual machines. We do not doubt any of what we have heard. We do not pass judgment and are not in a position to validate any of it, but we have made a recommendation on national medical devices standards and for assurance to be provided by the HSE for the Department on this issue.
With regard to legal and ethical issues, the coroner process formed a significant element of what families stated to us. The adversarial nature of the process was a big challenge for them. They found that it added to their grief and commented on the extent to which there was significant representation on the service side relative to their own. From our point of view, without any criticism of any individual coroner, the coroner system is operated through local authorities. Reports are collated and collected in local authority offices for the most part. Perhaps the extent to which intelligence is derived from each of these by analysing them at national level to try to identify patterns is more limited than it should be. We have started a discussion with the Department of Justice and Equality on this issue. It is already working on updating a draft 2007 Bill to update the Coroners Act 1962, to which an amendment was made in 2005.
Two other issues we dealt with are consent and confidentiality. Without going on at length about them, some of the dimensions of informed consent, a continuing challenge for health services generally, were deficient.
Without breaking confidences, one of the families we dealt with was under the impression that, as its members entered the operating theatre for an emergency caesarean section, they were signing a waiver, not a consent form. Until we were in a position to correct them, they continued in that belief for a number of years.
The other issue is that of confidentiality, in respect of which we have some findings or recommendations.
The Minister has covered a number of the conclusions, but I will read them as they are set out in the report's summary, section 6. We set out six overall conclusions that relate to the families first, then the service and finally the oversight. Two conclusions relate to each.
Families and patients were treated in a poor and, at times, appalling manner with limited respect, courtesy and consideration. Information that should have been given to families was withheld for no justifiable reason.
Regarding the service, poor outcomes that could likely have been prevented were identified and known by the hospital but not adequately and satisfactorily acted upon. We concluded that the service could not be regarded as safe and sustainable within its current governance arrangements, as it lacked many of the important criteria that were required to deliver, on a stand-alone basis, a safe and sustainable maternity service.
In terms of oversight, many organisations, including the service itself, had partial information regarding its safety that could have led to earlier intervention had that information been brought together. The external support and oversight from the HSE should have been stronger and more proactive, given the issues identified in 2007.
We have set out 11 overall recommendations, which are described over the course of three slides. Since the Minister has covered a number of them, perhaps it would be best if, instead of my reading them all out, members peruse them. I am happy to take questions on them and to explain the background rationale, if doing so would be of interest.
I do not propose to go into detail on the legislative and policy implications, but this report and its findings will have some implications for our ongoing work in both regards. Some examples are set out in the final two slides. In the interests of time, I will conclude now.
Ms Laverne McGuinness:
I thank the committee for its invitation to attend this meeting. I am joined by my colleagues, Mr. Ian Carter, national director of acute hospital services, and Mr. David Walsh, regional director for performance and integration in Dublin-mid-Leinster.
The HSE welcomes in full the findings and recommendations of the report of the chief medical officer, CMO, Dr. Tony Holohan, regarding perinatal deaths and related matters in Portlaoise hospital's maternity services from 2006 to the present. As members will be aware, the CMO prepared this report at the request of the Minister for Health, Deputy Reilly. It recognises clear failures in how risk and patient safety were managed in Portlaoise hospital during the period in question. It concludes that, under the previous governance arrangements, the maternity services could not be considered safe and sustainable. A new management team was put in place last Friday to address this matter.
The HSE accepts that there were significant shortcomings in the cases referred to in the report, particularly regarding the level and quality of care afforded to the patients in question and to the substandard communications with their families. The staff of Portlaoise hospital apologised unreservedly to any family that experienced care below the expected standard in the past number of years. On behalf of the HSE, I wish to repeat this unreserved apology for the failings in the care outcomes experienced by the families concerned and for failing to ensure that prompt incident investigations were undertaken. I also wish to apologise unreservedly for the unacceptable communications with the families at a time when they most needed honesty, compassion and kindness. The fact that timely investigations did not happen is unacceptable.
The report makes 11 summary recommendations and Mr. Carter has overall responsibility for their implementation. Three relate to the Health Information and Quality Authority, HIQA, and eight to the HSE. Steps have already been taken by the HSE to implement these eight, with three already implemented. Work has commenced to progress the other five. The HSE welcomes the involvement of HIQA in respect of three of the recommendations and looks forward to its input.
A new management team was appointed last Friday on an interim basis in order to run the service. This team consists of Mr. Michael Knowles, who has taken up the position of general manager at the hospital. Previously, he was general manager in Naas General Hospital. Ms Angela Dunne takes up the post of director of midwifery. She was previously the assistant director of the Coombe Women and Infants University Hospital. This management team will remain until a new governance arrangement is put in place. Dialogue has already commenced with the Coombe Women and Infants University Hospital in order to provide support to Portlaoise in a collaborative working arrangement for the future. The new governance arrangements will bring the appropriate vigour to maternity services in Portlaoise hospital. This is essential to restore quickly any loss of confidence that has arisen among mothers, fathers, families and the wider community that it serves.
The report concludes that families and patients were treated in a poor and, at times, appalling manner with limited respect, kindness, courtesy and consideration. The director general of the HSE, Mr. Tony O'Brien, has recently written to all staff within the health services highlighting the importance of honestly communicating with patients and families. In his letter, he wrote that communication failures, such as those experienced by the families referenced in the report, "erodes public confidence in Health Services, lets down the public and lets down the service as a whole". He asked all staff to address together the fundamental issues of culture that lead to such communication failures. In this regard, the HSE has recently published its policy on open disclosure. The policy ensures that services embrace and support an open, timely and consistent approach to communicating with service users and their families when things go wrong in health care.
The HSE shares the concern of the CMO regarding the promptness of incident investigation. An incident management policy, which is currently being updated by the HSE's quality and safety directorate, intends to reinforce the importance of speedy incident investigations. Furthermore, the HSE is conducting its own review into many of the concerns detailed in the report. While we await completion of that review, the HSE wishes to make it clear that it will take appropriate disciplinary action against staff members should the review deem that such action is warranted.
This report has revealed unacceptable failings. I reassure the committee and the community served by Portlaoise hospital that we will work with the new management and staff to ensure that these failings do not recur. This concludes my opening statement and, together with my colleagues, I will take any question members may have.
I thank Ms McGuinness. I wish to bring to members' attention the fact that Mr. O'Brien was invited but, unfortunately, could not attend. He has sent his apologies, but he has had a long-standing work commitment to a trip outside the country. This is why Ms McGuinness is attending.
I thank the witnesses for attending and for their presentations on the report. I compliment Dr. Holohan on his report and on his professional handling of same. I also compliment the Minister on meeting the families. It showed that what is often lacking for families in a time of crisis is a human face. The families appreciated it.
This is just the initiation of a longer and more in-depth review by HIQA. Although we will await the outcome of that report, there were clearly difficulties in Portlaoise hospital. For example, misdiagnoses in the context of breast cancer screening had already been identified. Since 2007, the HSE had been concerned. Dr. Holohan's report points out that other organisations were aware of difficulties within the hospital and that, if the information had been collated, alarm bells might have rang sooner, preventing some outcomes. We will never know. What are those organisations? Are they the HSE, worker representative bodies, clinical professional organisations and so on?
When launching the report in Portlaoise and meeting the families, Dr. Holohan stated that the number of staff was not specifically the issue of concern.
Even though there may not have been staffing problems on the day in question, given the increase in the number of births at the hospital over a sustained period, staff are under pressure all of the time. This suggests that corners start to get frayed, shortcuts are taken and management is challenged. It is a concern if clinicians do not have the time to question and to fill in their reports properly. There appears to be a problem with reportage.
One must conclude that, on the clinical side, people were beginning to indicate that there had been problems with patient safety in the maternity services for some time. From what I can gather from discussions with people involved in the hospital, concerns were relayed by nurses and front-line staff to management several times. That they brought them to local politicians as well is a written fact. While we must hold to account those who should be accountable, it seems that the maternity service was almost operating in isolation of managerial oversight. Will the witnesses comment on this point?
Committee members met the families and saw their emotion at the report's publication in Portlaoise. They were treated in an appalling manner. That such a thing could happen is incomprehensible on a level of basic human compassion and kindness. If a system becomes reactive, insular and sensitive when families face these circumstances, it must be changed.
Was the culture of a lack of openness and co-operation ingrained in all of the staff or just some management? How did it come about? Is it in other maternity hospitals and the health service in general? We have discussed whistleblowers in other forums, but when people, particularly front-line clinicians and patients, raise issues of concern, I have found there to be a resistance in the system to accepting the veracity of those claims and to investigating in more detail as to whether the complaints have merit. At times, we dismiss clinicians who highlight issues of patient safety. Consider the new contracts for general practitioners, GPs, and consultants and the clauses on prejudicing the name of the HSE. Is everything becoming more secretive? If so, it puts more pressure on contract employees of the HSE who want to be open and honest if they believe there are problems. The Garda Síochána is a disciplined force, but it looks like the HSE is one as well. Never should one question authority up the line.
An open disclosure policy would be a major step in the right direction. I am not just referring to cases where the clinicians accept that they got it wrong. Rather, management and the entire system should be open about addressing problems instead of hoping they will go away or can be avoided. I am not making a criticism of any individual. The system just appears to be resistant to any form of accountability. We should not start witch hunts, but if someone is clearly unable to do his or her job, questions must be asked of that person regardless of whether he or she is a manager, a clinician or anything else. I hope that the policy of open disclosure will begin to permeate the organisation as a whole.
Has my time concluded?
Indeed. The issues of the coronial process must be viewed seriously, in that there seems to have been an effort not to co-operate fully with investigations. Statements made at the coronial process may not correlate with written notes, etc. This is a serious charge and, if true, must be put right quickly. One could argue that, if people are not co-operating with their statutory obligations under the coronial process, the matter is so serious that others should be examining it.
We must not launch a witch hunt, only find out the facts. If some people are genuinely not up to doing their jobs, be it in Portlaoise or anywhere else, they must be held to account. If they cannot be supported, they should be moved elsewhere. We cannot jeopardise life-and-death services.
When information is brought to local management and senior management at national level is concerned about problems at a hospital, who oversees the former or does the issue just stop at that level without any oversight? In this case, it had been evident since 2007 that management and governance structures were weak. Issues were brought to the attention of the authorities. Perhaps we should have a system of reporting that is more efficient than merely contacting a local Deputy who writes a letter to someone else who then writes a letter to someone else and so on before it eventually falls into no-man's-land. Perhaps there should be a clear demarcation of responsibilities so that, when a complaint is reported, someone must act on it and ensure it is investigated. If concerns arise from that process, they can be addressed. If they do not, the complaint can be dismissed.
As I did last week, I welcome the publication of Dr. Holohan's report. At the outset, it is important to say that this is not a presumption - I am certain that it is the case that what we all want to see is a safe, highest standard maternity service for women who need that service, not only at Portlaoise, but at all maternity units throughout the country. Anything that helps to ensure that is the case and guarantees it to women is welcome. It is very sad, however, that we have had to see all of this focus and light shone on failures and inconsistencies as a result of tragic outcomes. That is always very sad indeed.
I would welcome and highlight many parts of Dr. Holohan's report, but I have to ask a question. It does not anywhere in any serious way reflect on staffing levels at the Midland Regional Hospital's maternity service. It does not focus on the fact that maternity-midwifery staff had highlighted back in 2006 the serious understaffing at the Portlaoise hospital maternity service, PHMS. Why is that the case? While even the Minister acknowledged in his address this morning that failures were identified at both local and national levels, there is no doubt but that there is a failure at national level to heed the concerns of front-line maternity-midwifery staff, and those working with them in obstetrics, over a series of years and a series of Governments. We cannot simply focus in on failures of individuals or the hospital system to the exclusion of a failure to not only address a problem highlighted a number of years ago, but one that has been compounded over the period since by a continual drain on staffing provision and resourcing.
The Minister stated that had the data obtained been collated and examined it would have pointed to there being a good reason to suspect an ongoing problem with outcomes of care. The Minister also stated that birth rates had risen very quickly over a short period. How does that sit with concerns in relation to staffing levels having been raised as far back as 2006? There clearly was a cry from staff in that regard? I do not believe it is sufficient to say, as Ms McGuinness did in her concluding remarks, that in the event the HSE's review establishes that certain actions may be warranted, appropriate disciplinary action would be taken. I do not for one moment excuse any failures of the highest conduct and behaviour on the part of our hospital staff at any location. Nothing excuses it. We cannot look at this in isolation and say that is the problem while ignoring the elephant in the room, which at the end of the day must be the fact that there was inadequate staff provision. That point has been made point after time.
The INMO response to the report highlights a factual position. It is not a case of the INMO doing its business representing its members, which job it does very well, rather it is a fact of life that we have a midwife to births ratio at the Portlaoise site of 1 to 55. The recommended ratio is 1 to 29.5 births. The INMO has called for the immediate recruitment of 33 additional midwives at the Portlaoise hospital site. I would like the Minister to comment on those points and would welcome his reaction to the INMO position in relation to the need for 33 new staff. The Minister in an exchange between us in the Dáil on 13 February on this issue stated that the hospital had approval to recruit additional midwives up to the approved complement. Will he advise what that complement is? While I put that question to the Minister on the day in question he did not respond. When did approval to recruit additional midwives issue and what is the approved complement? Does it come close to the identified need of 33 additional midwives at Portlaoise hospital?
The Minister spoke in his contribution of the commencement of a midwifery workload and workforce review by the HSE. Can he advise what the timeframe is for that review and when the report will present? I note that the Health Information and Quality Authority, HIQA, is to undertake an immediate investigation of Portlaoise hospital maternity services and to report by the end of the year. Why in this instance is a timeframe of up to nine months provided when no timeframe is set out in respect of the HSE review? The Minister has indicated that a planned development of a national maternity service strategy will be delivered this year. I am trying to put each of these pieces of the jigsaw into some order. Is it possible that a national maternity strategy would be delivered in advance of some of these reviews and reports or does the Minister see it as a natural lead of one informing the other? I would welcome if the Minister could clarify that situation.
In relation to the inconsistencies referred to by the Minister in relation to perinatal data collection, will he outline exactly what inconsistencies have now been identified that have given rise to an under-reporting of perinatal deaths across this State?
It is important to thank the families who have persisted in raising these issues. It is also important to thank the Minister for the manner in which he has dealt with the situation and to welcome the report of Dr. Tony Holohan, the chief medical officer, in relation to this matter.
There appears to be unprecedented failures here. It is truly shocking to learn of the lack of respect and due care for families at such a sensitive time. They were treated appallingly. As someone who worked in the hospital services for more than 20 years I am at a loss to understand that. I also find the culture outlined in the report completely foreign to my experience. It appears from the report that there was a breakdown at every level of responsibility and authority not only at Portlaoise hospital, but at national level. I have listened to the commentary on this issue and have read various reports on it. It is not clear from those reports why this happened. It appears to me that the significant reductions in expenditure nationally, including the 11,000 reduction in staff, has put enormous pressures on staff, in particular at Portlaoise hospital. There is no excuse for any staff member at any hospital not treating people with due care and respect or providing quality service. However, there is no doubt that staff are under constant pressure.
I understand that a number of posts at senior level in Portlaoise hospital were filled on a temporary basis only and that 25% of staff, nursing and medical, are agency staff. Deputy Ó Caoláin referred earlier to the ratio of midwife to births at the hospital being 1 to 55 despite that nationally it is 1 to 29.5. This coupled with the aforementioned staffing issues suggests to me that there are serious pressures on staff in that hospital. Another significant matter highlighted in the report is that of the concerns raised by staff at a number of levels. What action was taken as a result of those concerns being raised? It is not clear from the report what happened in that regard. Also, what procedures are in place now to address future concerns raised by staff?
I welcome the HSE statement in regard to the open disclosure policy. I hope it will not be only a policy but will be acted upon on a daily basis within and throughout the service.
I welcome the publication of the report and thank the families for highlighting the issue and forcing action to be taken. Other members have raised the issue of staffing levels being extremely low, particularly with regard to midwives. Has the reason for this been identified, as the report does not seem to indicate it? Why were levels so low and why did vacancies continue? Is it a continuing issue within the hospital system, as I am sure there are plenty of qualified people out there? Were qualified people not prepared to work there? What is the turnover of staff? The report did not deal with the numbers passing through over the past six to seven years.
The second issue relates to medical consultants. The birth rate has gone from approximately 1,000 births to in excess of 2,000 births per year, meaning there is one consultant for every 800 deliveries approximately. I understand in some English hospitals the recommended ratio is one consultant to 350 or 400 deliveries, so we are at double that rate. There are three consultants and six registrars in the facility. They operate a so-called one in three call, which is being on call every day, every third night and every third weekend. Every third weekend the consultant would be on call from 9 a.m. on Friday to 5 p.m. on Monday, and we have withdrawn rest days in some units. There would have been a rest day for each weekend worked but they have been withdrawn. We are talking about understaffing in real terms but we have withdrawn a rest day provision for people working those kinds of hours. What is the current position of the Department and the HSE in that regard?
One of the big complaints I have heard from both nurses and other medical practitioners concerns turnover of managerial staff, but the report does not deal with how many different people were in charge of management between 2005 to the current time in the hospital. If the same people are not in charge, new people must start over and issues get put to one side.
I came across a case where a death occurred in a hospital but 18 months later a coroner's inquest had not been held. In fairness, the hospital did everything by the book and contacted the State Claims Agency to investigate if pressure could be put on the coroner to hold an inquest. The families were concerned about a potential cover-up because the inquest had not been held. There was no reason given by the coroner for not holding the inquest. What are we doing about that and ensuring inquests are held in a timely manner for everybody concerned, including hospital staff, medical and managerial people and, most important, the families involved?
I thank the Minister, Dr. Holohan and Ms McGuinness for providing the report. The very basic rights of care - compassion and respect - are very important, whether one is going to a GP or a hospital and whether one is pregnant or going for any other reason. There seemed to be a failure in this case. The report made me very angry, sad and, above all, made me believe something broke down in a hospital that is meant to care for people. I am not fully convinced it was anything to do with staffing levels, as we do not need 20 or 40 people to have a bit of compassion in a room. Only one person is required to put an arm around another and say "sorry". It takes one nurse or doctor to hand a dead child back to a mother to allow her hold it. It does not take 20 people to do this. When we consider numbers and staff levels, it does not mean much with this report.
The words that stick out most are the conclusion of the report, which indicates that families and patients were treated in a poor and at times appalling manner, with limited respect, kindness, courtesy and consideration. These are the basic rights of any normal human being going about his or her work. Politicians are at times said to be heartless and without feelings, but if I did not have compassion and respect, among other qualities, in dealing with people on a daily basis, I would not be in this job. I would not have the right to be in it.
I am glad Ms McGuinness has indicated there will be disciplinary action when the report is finished. I do not believe that, any time of any day, people have the right not to do the job they are asked to do, particularly to care for people. The most devastating consequence is to lose a child, either during a pregnancy or at birth, as it leaves a parent with a terrible void. There is a constant question of whether things were done correctly and if the mother did everything right during pregnancy. These women will ask if they could have done anything before the birth of the baby that would have saved it.
The findings of the report are appalling and make for very sad reading. There is real reluctance for some to do their job right and in a compassionate manner. I hope when the report is published and people are identified as unable or unqualified in their job, they will be disciplined severely. A lady beside me is expecting a baby in a few weeks and I have a daughter and a niece expecting a baby, so I hope that staff in the hospitals they use will treat them with, above all, compassion and some dignity. It is a tough and anxious time for expectant mothers and fathers, as well as grandparents. We must see some compassion. God almighty, a parent holding a dead baby is a sad occasion and people should rally to do as much as possible. We failed these people dreadfully. The HSE has failed them, but most of all, staff have failed in a duty to perform as medical care workers.
I welcome our guests and extend sympathy to those who had tragedies visited on their families in Portlaoise. I will try to act in a fashion becoming of the Parliament but I must be harsh. All I can say is this room reeks of whitewash, and I am sorry this report does not address core issues. I mean no personal disrespect to anybody but people employed in the Department and HSE have grown up in a certain culture with a method of dealing with matters in a corporate fashion that colours the way in which they see the service and its customers.
We can go through some facts. As my colleague, Senator Burke, has pointed out, the number of births increased from 1,000 to somewhere between 2,000 and 2,500. The number of consultants, already fairly ludicrously low at three, stayed at three. This was a time when this region had an influx, for unusual demographic reasons related to the real estate market, of young couples occupying pseudo-dormitory commuter communities. There was a disproportionate number of young people coming in at a time in life when they would be starting a family. The national birth rate in these years went up by 17% but in Portlaoise it went up by 50%. To reiterate the point, the number of consultants - which was inadequate at three - stayed at three. When Dr. Holohan states his belief that staffing issues had nothing to do with this, I must ask him why the Department of Health and the HSE allowed this place to be overstaffed when there were only 1,000 births per year if three consultants was the appropriate number when there were 2,500 births per year.
Added to this are the non-consultant hospital doctors, or to call them what they are, trainees. As I stated before, if an engagement ring is dropped down a drain, one would not expect an apprentice plumber to fix it but we are quite happy to let precious children, our wives, husbands, spouses and parents to go to hospital every day and be treated by non-consultant hospital doctors.
The reason is that by fiat of successive Governments, the permanent government, the Department of Health and its more recent offspring, the HSE, there was a policy of having a ludicrously low level of career level posts in our country. Recently, applications were invited for specialist registrar positions in obstetrics. I will put my cards on the table. I do not believe those people should be regarded as anything other than trainees. I do not care how senior or qualified they are, they are trainees. However, even for this level of training, there were 13 applicants for the 16 jobs and only nine were considered to have met the minimum educational requirements to do it.
Portlaoise hospital was not even recognised for training, so why was it employing NCHDs? Why are trainees working in a hospital which is not recognised for training? From where did they come? Were these people the well-meaning, good people who are often trained in other countries and come to this country seeking experience and are then exploited by being put into jobs which are not recognised for training, to provide cheap labour for a system which will not employ the appropriate number of career level consultants? Were any of them part of the process of us recruiting in medically under-served countries to poach their doctors to come and work here? This is not an isolated matter. We have discussed it previously and I was less than impressed with the response that was given when I pointed this out following the tragedy that occurred in Galway 16 months ago. Galway is the region not just in Ireland but in the entire OECD that has the lowest number of consultant obstetricians per head of population, yet we are told it is entirely coincidental that these types of tragedy occur.
We have been whitewashed over the years with the reassurance that at least our perinatal mortality figures are good. My mind has been blown away by this report. Now we do not know what they are. We might have miserable perinatal mortality rates because the witness is telling us that nobody is recording them appropriately. I am not impressed by this and, with great respect to the undoubtedly genuine human sympathies of the people from the HSE and the Department of Health and their interactions with these poor families who suffered such tragic losses and, it would appear, were treated poorly, if they really wish to be sincere in their sympathy and not shed crocodile tears to mix with the whitewash, they will fix the problem.
I have another question. Were consultants involved in the two episodes of foreign bodies?
I welcome the witnesses. For somebody who is quite distant from this, one's first concern is whether this is happening in isolation or in other places. Hopefully, it is rare but I would be surprised if it is isolated. The Minister said that other maternity services are being examined. When are we likely to get the results of that examination? That would ease many of the concerns among the public about the maternity service. Undoubtedly, this has put a question mark over all the maternity services, regardless of how unfair that might be. How long was the governance and system of delivery of service, as the investigation found it, taking place? Was it recent, ongoing or historical? If it was not historical, what triggered it? Did events trigger it? Was it a change in staff? What change occurred to trigger what happened?
What is the reason for not informing the family of what happened? Was there a reason or was it just neglect? We find this in other parts of the health service. There is a reluctance to inform families and carers when people are in need of care.
Finally, in most sections of the old health boards, including the health board in the mid-west, there was a clear complaints procedure. We all used it from time to time in respect of people who had complaints about the service they were given. Was a complaints procedure available to the people and families who suffered so much in this instance? Was it operating or were they made aware of such a procedure? What was the response if they did use the complaints procedure?
I thank the members for their contributions. Nobody here does not wish to have this problem fixed. In the past there was a sense that when hospitals became unsafe, reports were carried out to confirm the fact that they were unsafe, and to use that to close them down. That will not be the case here. This report will be used to fix the service.
Deputy Kelleher raised a number of issues. Some of his questions are better directed towards Dr. Holohan, such as what are the other organisations alluded to in respect of having information. I am acutely concerned about the issue of bringing concerns and patients' concerns to the fore. That is the reason I wish to set up a patient safety agency this year, in order that people will have a patients' champion and advocate who is clearly on their side to pursue their issue, whether it is something dreadful and tragic as happened in Portlaoise or just a small matter. It will be there to support the patient, to pursue their issue with them and to direct them how best to get satisfaction. I have stated on the record many times that what most patients want, in my experience, is an acknowledgement that something went wrong, an apology for what went wrong and an assurance that it will not happen again because things will change. That is at the root of the problem in Portlaoise. Reports were produced and recommendations were made, but they were ignored.
That brings me to a broader point, which the report addresses. It is the fact we do not have an outside monitoring system for the implementation of recommendations of various reports throughout the country. One of the recommendations in the report is that HIQA should engage in such a monitoring process. The patient safety statement and patient surveillance will aid that. What Deputy Kelleher alluded to and what Dr. Holohan discovered is that the information was available if one went looking for it in different places, but nobody was collating it and putting it together in order that they could see there might be a problem and it should be checked. What we are depending upon is the bravery and tenacity of parents in this case or somebody in the hospital to put up their hand. That is not a good system. We must have a monitoring system whereby we can objectively identify something. It is like a fire alarm. It might be nothing or it might be something really serious, but we must have a system in place that alerts us to it.
I welcome open disclosure. We opened a conference on it and it is running on a pilot basis. Dr. Holohan was there that day with the HSE. There is great acceptance of this throughout the system and people see the value of it.
The Deputy mentioned the GP contract and the line that is being interpreted by GPs with some concern about what they see as a gagging clause. I wish to put it on the record that, as Minister for Health, I would not preside over a situation where people could not voice their concerns. However, I am equally aware that many employers have a line in their contracts which ask people not to bring the organisation into disrepute. That is more about behaviour, not about not voicing one's concerns. I point out that the wording in that area can be changed in order that it does what it is supposed to do, which is remind people of their responsibility to the organisation in terms of not bringing it into disrepute, but by no means does it infer that they are gagged or cannot speak out if they are concerned about what they see as wrong, unsafe or any other concern.
In these situations a balancing act is required. On the one hand we must hold to account individuals who have failed in their duty. On the other hand we do not wish to have a witch hunt. We certainly do not want the morale of the staff in Portlaoise, many of whom are excellent people, to be further damaged. We must support them to grow and give of themselves, in a way they had always intended, to the local people. All the parents were very clear with me.
They did not want the service closed but made safe and I support their wish 100%. That is what the report is about.
I regret that some people feel the report is a whitewash, but I do not think it is. If one listens to the parents - and I have listened to one on the radio who made it very clear - they had all of their concerns written down and when they read through the report they were able to tick every box because each concern had been addressed. Notwithstanding the cynicism that sometimes surrounds this House, we listened, we heard and we took things on board. As I said in my opening remarks, we must ensure that we do not fail parents and patients again by not ensuring that the lessons learned here are learned not just in Portlaoise but right throughout the health service. That is what HIQA monitoring will ensure.
Members also asked about local complaints procedures, and Dr. Holohan will address the matter in a more cogent way than I could, but I will simply say that people do get frustrated. Most hospitals have a complaints officer. If people do not get satisfaction they will resort to the law, because that is the only way for them to get satisfaction. What the parents had to endure was shocking; there is no other way put it. It is astonishing that one must go to court to get one's notes. We now have an opportunity to change the culture completely. I am at pains to point out that this is our health service - everybody's - and it behoves us all to be engaged and to change it to one that we would want for ourselves. Tony O'Brien sent a letter to staff two weeks ago and made it clear to them that people should be treated with respect and compassion in the same way they would want their loved ones to be treated. Deputy Catherine Byrne mentioned - and I agree with her - that it must be key, and everybody here is in agreement about that issue.
Deputy Ó Caoláin raised the issue of staffing levels. In response to his query and that of Senator Crown, nobody is saying that staffing levels might not have had an impact in this case. We are saying that it does not explain it all. It does not explain, when there was nobody else in that unit on a given night, how the failures occurred; it does not explain the culture and attitude. What was done was unacceptable at a human level and we must change that. Nobody here would disagree with my wish.
I shall pass a few specific questions to Dr. Holohan. I have addressed the issue of the early warning signs and HIQA reporting and monitoring. Dr. Holohan can talk about the approved complement of the HSE, because I do not have that information to hand. The workforce planning will be finished by the end of the second quarter of this year. The plan will inform all of the national maternity strategy, as will other reports that are available to us.
Obviously everybody is very concerned about the perinatal death statistics if they are not accurate. We have found that to be the case and so we will improve the situation. We must have evidence in order to make proper decisions on health care, and information technology will help. However, information technology is only as good as the information that is fed into it. There was the old acronym GIGO, which means "garbage in, garbage out". We must ensure that information is collected properly.
Deputy Healy raised the issue of nursing concerns and staffing levels, which will be addressed by Dr. Holohan. Senator Colm Burke talked about low staffing levels and wondered whether that was still the case. He asked for the ratio of consultants to patients and deliveries, and asked what were the normal or internationally recommended ratios and how much managerial change has taken place since 2005. Perhaps the HSE will address these matters.
Obviously the coroner delays are of great concern. We want to see changes in the coroner's approach. Sometimes we do not need to legislate but we must outline definitions, and there must be a willingness to change. My view is very clear: there should be an inquest in respect of any baby that dies once labour begins. This will deal with what some parents felt was an attempt to label deaths as stillbirths so that they would not require an inquest. There has been a huge breach of trust at so many different levels here. We will rebuild the trust. We will turn Portlaoise into an exemplary hospital over the next number of years.
I have already addressed the issues raised by Deputy Catherine Byrne. She did mention that patients should be treated with compassion, kindness, care and safety. No amount of kindness and compassion can make up for incompetence.
I will let Dr. Holohan deal with Senator Crown's assertions. Deputy Neville asked the pertinent question of whether this is happening elsewhere. I want to be assured that it is not happening elsewhere but I cannot be assured of that at the moment. That is why we are reviewing other maternity hospitals of a similar size, and all maternity hospitals, to ensure that the recommendations that came out of the tragic death of Savita Halappanavar will be and are being implemented. I cannot be sure that this has happened. With no disrespect to the HSE or the people who work in hospitals, it is not good enough for us to just accept it when a hospital says it is doing something and that is the end of it. We must satisfy ourselves that hospitals are doing what they say they are, and so we must have outside monitoring. A question was asked about whether something triggered this case. Back in 2005 it was a cultural thing that seemed to grow at the hospital. I will ask the chief medical officer to address the remainder of the questions.
With respect to the Minister, his expression of compassion and sympathy for the families concerned is very obvious, but he has not engaged with the members present or answered our questions. I asked a question about the Minister's statement on Portlaoise hospital in the Dáil on 13 February in which he stated: "The hospital has approval to recruit additional midwives up to the approved complement." When did that approval issue? What is the approved complement? Does it come close to the ratio that was outlined by the INMO? I asked him to be specific about the inconsistencies. Today he mentioned the "systematic under-reporting of perinatal deaths due to inconsistencies in Ireland’s perinatal data collection." Will he outline those inconsistencies, please?
With respect, I do not want this to turn into a row, but I did say in response to the Deputy's questions that Dr. Holohan and the HSE would address his issues. I ask him to give them an opportunity to address the issues.
Dr. Tony Holohan:
Deputy Kelleher asked about the other organisations involved. As I said at the beginning, we interacted with a number of organisations at a national level. In particular, we know that the State Claims Agency and HIQA had information that gave them cause for concern about the service and they shared their information with us. Some of that data is now in the report, and figure 4.6 is an example.
We also asked some of our national regulators. We asked the Medical Council and An Bord Altranais because they have a relationship with services on the ground and sometimes deal with complaints, so that would give them a perspective on what may be happening in a given service. Also, they have an inspecting role in education and training in services, which would also give them a window on what is happening. We asked them about all issues of this kind. We did get information that allowed us to say that certain organisations at national level had information that gave them cause for concern and that they were raising them with the hospital at a local level.
With regard to staffing in general, I will provide information to complement what the Minister has said. He was correct when he said the report did not say that the staffing issue was an explanation for what happened here. It was saying that it was not the only explanation, which is far more complex. Frankly, staffing cannot explain the situations that we discovered - individual cases that occurred in isolation with no other patients on the ward and with a full complement of staff at that time. It does not explain the behaviours or the way in which staff spoke to, treated or interacted with staff or patients in a given situation.
We do know that there was good reporting. The level of adverse incident reporting was comprehensive in the sense that staff were completing reports, but we think that was part of the overall culture.
The response to patient safety issues was one of completing a form and sending it away to the State Claims Agency. Frankly, it is my personal view that it is not sufficient for a health care professional to discharge his or her obligations to patients in terms of patient safety by writing letters to Ministers or others about staffing levels. That does not mean, however, that it is not appropriate for staff to raise issues at a local level.
Deputy Ó Caoláin specifically asked me for my view on what the INMO has said. I have seen what that organisation has said about staffing levels but I am not aware that the INMO has made any comment whatsoever on the behaviour of staff, which, in my view, was central to the findings and central to the issues before us. While I am not accusing anybody of trying to simplify things, the INMO's interpretation would be, for me, an oversimplification of a very complex story. Deputy Catherine Byrne's analysis is much closer to ours in terms of explaining what happened. We make clear in our report that there was an increase in the number of births which was not matched by an increase in the number of staff. We also make clear that there were difficulties in recruiting staff and that there were leadership positions vacant which, in my view, are very important in explaining some of the findings that were set out in the HSE's own individual reports about supervision, handover, escalation and so forth. We make clear recommendations with regard to Birthrate Plus and a number of other measures that must now be used as a benchmark. There are certainly issues with regard to staffing - I am not saying that staffing is not an issue - but it is not the sole explanation for what happened here. We cannot allow ourselves to conclude that a problem with staffing allows people to abdicate their responsibilities in terms of looking after patients sensitively, kindly and compassionately or reporting harm to patients honestly and openly when it happens, because that is an inevitable consequence of health service delivery.
Deputy Kelleher and others asked whether this is happening elsewhere. As the Minister has said, that is part of the reason for saying that the implications of this report must be examined by the HSE in the context of other similar-sized services. That is also reflected in the recommendations on the investigation that HIQA will conduct. In particular, it is reflected in the recommendation that the hospital groups mechanism should be the direction of travel in the reorganisation of hospital services. There is enough reason for us to say that we should get on with the linking of smaller units into larger units within the hospital group areas.
Is Dr. Holohan saying that linking the Coombe hospital with Portlaoise hospital will be replicated by the linking of the maternity unit in Kerry with Cork University Hospital and so forth in the future?
Dr. Tony Holohan:
This is recommended in the report. We do not need to have another investigation of this kind or another report of this kind to tell us that we need to get on with that reform. It was already part of the direction of travel and we are saying that it needs to happen forthwith. There are similar-sized units in other parts of the country. We did not investigate them so we cannot say that any of the problems we found in Portlaoise are happening there but some of the ingredients that are important in explaining what happened are evident in some of those smaller units. In that context, there is a justification for proceeding quickly with the direction of travel.
The coronial process was mentioned a number of times and questions were raised about the timeliness of it. In one case a family was waiting for a number of years for a coroner's inquest to take place, while another family, for whom the incident took place at a much later date, went through the inquest at more or less the same time. That added to the family's distress. As I said earlier, we have already commenced a process of engagement with the Department of Justice and Equality regarding this issue. A report was published in 2000 on the coroner process which provided the basis for amendments to the 1962 Act in 2005. A draft Bill was prepared and it was recommended at the time that a national coroner service be established, along with other measures which are still being examined by the Department of Justice and Equality. We want to engage with the Department to make sure that some of our findings are reflected in its review and its plans to update the legislation.
Senator Colm Burke asked a specific question about management turnover; the HSE might be in a better position to answer that. Without getting into semantics, it is important to point out, in the context of what Senator Crown had to say, that this was not a training location on the specialist registrar, SpR, training programme in obstetrics and gynaecology, although at least one individual was part of basic specialist training, BST, training in obstetrics. It is a training location in both obstetrics and paediatrics as part of the local GP training scheme but there was no specialty-specific training happening in Portlaoise. These people were not trainees. The junior hospital doctors were in service posts. I should have added, in what I said about staffing, that the report sets out the data very clearly on what has been a fairly recent trend towards increasing dependence on agency staffing in both medical and junior hospital doctor provision, whereby the expenditure on agencies for that service is somewhere in the region of €1 million now as against an expenditure of zero in 2007-08.
I hope I have answered Deputy Neville's question about whether what happened at Portlaoise is happening elsewhere. I may have missed a question or two along the way and am happy to be reminded of them if so.
Was the difficulty in retaining and recruiting midwives explained in the report? Did the authors find out why there were recruitment difficulties? There are a lot of qualified midwives out there and I do not understand why there was a difficulty in recruiting. Has an explanation been found as to why people were reluctant to go to work in Portlaoise?
Dr. Tony Holohan:
In the time period we have not been able to answer the question of why, but they are of course legitimate questions. This report simply sets out what happened. It provides the data on the number of posts, the numbers not filled and so forth. There are potentially many reasons these posts were not filled but we did not attempt to analyse the reason in that regard.
Another question I overlooked concerned whether there was a trigger for all of this. I do not think it was a single event but rather the fact that, over a period of time, a culture became ingrained-----
Dr. Tony Holohan:
All we have looked at is the hospital in Portlaoise. We talked to patients and families who were users of the service and we talked to the staff and those who had leadership responsibilities. It appears that a complex culture developed over time and, without wishing to sensationalise, it is very similar to the findings that were set out in the Mid Staffordshire investigation in the UK. That same sort of culture that has been the subject of a lot of writing in the UK was evident here.
Were the foreign body episodes laid at the hands of the consultants, nurses or NCHDs? What recruitment process was used to recruit the junior doctors who were in these unrecognised non-training positions, whose very existence I would question?
Dr. Tony Holohan:
If I may, I will leave the second question to the HSE. On the first question, I cannot say whether the actual incidents were directly the responsibility of consultants, but each of the two patients - the subject of these "never events" - was under the clinical care of a consultant who had overall responsibility for the care delivered to that patient. In that sense, the consultants have a responsibility.
I left out Deputy Ó Caoláin's question regarding perinatal death data, for which I apologise. There is a paragraph in the report that tries to summarise or explain the gaps in the data. It says that the General Registrar Office, GRO, receives a higher number of stillbirth notifications than the National Perinatal Reporting System, NPRS. Even though such notifications come from the same location, the GRO gets a higher number of stillbirths notified to it and it reports on them. With regard to the other component of perinatal deaths, known as early neonatal deaths, covering death up to seven days of life, the NPRS gets more early neonatal death notifications than the GRO. There is under-reporting and under-registration of early neonatal deaths to the GRO. That finding in the report is one that I am not sure anyone was aware of. A statistician from the CSO who works with us in the Department and a public health specialist worked solidly for seven days analysing all of the different sets of data, and their work provides the basis for the eight-page analysis set out in the report.
We have made it available to the Department of Social Protection and we will be in discussion with the Department in respect of what needs to be done to tighten it up and ensure we are reporting on the same, and the correct, definition. Our recommendation is that the hybrid, which corrects the two under-reporting factors, is used but it will not make any difference to our overall ranking. The idea that this is a complete misrepresentation of what our perinatal mortality rates says about the safety of our system is not the case. What we observe in respect of perinatal mortality is that, given that information available in units is not being looked at, perhaps an undue over-reliance on the perinatal system, referred to as the "burglar alarm" by the Minister, is not appropriate to be examined in isolation.
I want to make one point before handing over to Ms Laverne McGuinness who will take the questions posed by Deputy Ó Caoláin on staffing. While it will not make a huge difference to our overall ranking, it is extremely important to patients and to parents who have had a stillbirth or lost a baby that it is recorded. It diminishes hugely their trust in the whole system and our statistics if their baby has not been properly recorded. While it will not make a huge difference in terms of statistics, it makes an enormous difference at the human level for parents.
I seek clarification on whether Ms McGuinness will respond to the staffing levels approved to proceed at Portlaoise hospital.
Dr. Holohan made a remark about the INMO statement. It would be unfair to suggest it was in some way immune to the concern there. Reading it, it records that these were terrible tragedies and involved human heartache. It pledged full support for the recommendations and implementation at the earliest opportunity. The witnesses have not answered the question about the fact that Portlaoise hospital had double the recommended ratio of live births to midwifery staff.
Ms Laverne McGuinness:
Deputy Ó Caoláin asked about the most recent recruitment. In July 2013, approval was given for up to a complement of 38 midwives and two additional shift leaders and a clinical nurse manager, grade 3. A renewal campaign is under way to recruit over and above the 38. Mr. Ian Carter will provide more detail on this.
A question raised by Deputy Neville concerned the management and administrative staff turnover. There have been changes at a number of levels, at hospital level and above, since 2006. A new general manager went to post last Friday and a new director of midwifery services also went in last Friday. Dialogue has already commenced with the Coombe Women and Infants University Hospital regarding collaboration. Mr. Ian Carter can expand on this point.
The last question concerned NCHDs and what is being done in respect of Senator Crown's question on the recruitment of NCHDs. Mr. Ian Carter will elaborate.
Mr. Ian Carter:
The recruitment that has commenced is open-ended. It involves working with the new director of nursing in trying to fill the basic grade of midwives and, as the CMO identified, to fill shift leader posts. I will take advice from the director of midwifery in the post at the end of this week to see how we shape the final skill mix. She is the best person to advise me.
With regard to consultant staff, we stand at four consultants. The locum deployed over the past few weeks will be maintained for the remainder of the year. With regard to the review being undertaken by me and the clinical management team in Portlaoise, it is under way and I hope to conclude it within the coming few weeks.
Two specific points were raised about whether there was a rationale for families not being informed of incidents or reports. From talking to the staff, no rationale was given. That is at variance to the policy on complaints or clinical incidents. No reason was cited but it is totally against the complaints procedure. In terms of retention of foreign bodies, there were two incidents relating to swabs, one of which directly involved a consultant and one directly involving an NCHD.
The last question referred to the overall audit of maternity services. That will be done within the framework of looking at forming groups but the exercise will be completed. It will look at maternity hospitals and small hospitals over the coming two months.
In the context of Ms McGuinness's closing remarks about disciplinary action that may arise here and, generally, across the board in the health service, is the culture of people being allowed to remain in positions and not held to account at an end? Out of this, surely we will see people who are meant to be in charge being held to account here and in general. I do not want to pre-empt any inquiry. We are talking about restoring confidence, which we want to do in respect of this issue and this hospital. We acknowledge the tremendous work done by many wonderful staff. Surely there comes a point where we cannot allow the same people to be in charge after what has happened.
Ms Laverne McGuinness:
There is a disciplinary process within the HSE across this and all hospitals and across the entirety of the community services and administration. Every year, a significant number of staff go through the disciplinary stages 1, 2, 3 and 4. Stage 4 is the most significant, where the staff are dismissed from the service. We have a full report on the statistics and it is a matter of holding people to account. It is very serious when it gets to stage 4. We bring in an independent person from outside the region to carry out the process. There is also an appeals procedure and we can provide statistics on this in respect of the people who have had to leave office. It does not get published widely but we do have it. When serious issues arise, which may involve fraud or clinical or various other matters, disciplinary measures are taken.
I referred to the withdrawal of rest days. The amount of work consultants in these units are required to do has doubled over the past eight to ten years. We have now withdrawn rest days for working weekends, with one in three on call in 11 units around the country. The second issue risk refers to the changeover of managerial staff in the smaller hospitals around the country, which is causing problems. It is something the HSE should examine. It cannot be dealt with in this report but it is a major factor in accountability and ensuring patients' genuine concerns are followed through.
I think the Chairman for this opportunity. I welcome the report and the fact that HIQA will carry out an inquiry. I am familiar with the hospital as my two children were born there and I was present. My grandchild was also born there. One of the things that concerned me, particularly in recent years, is that at a time when many people came into the area and the demographics changed as it became a dormer area on the outer ring of the commuter belt, many people came from eastern Europe. Eastern European constituents came to me throughout the 2000s and told me they were going home to have their babies because of concern about maternity practices in general, not just in Portlaoise. I mention that for what it is worth because it raised concerns.
We do not have a national policy on the use of syntocinon. I am not a medic but I have followed the issue of the use of the drug. It is used in the active management of the birth to shorten labour time. My concern is that the average induction levels are at 31%, whereas the WHO reports that it should be below 10%. The gap is a major concern and there is international concern reported about the overuse of this artificial induction drug.
It is reported that the Minister is looking for a standardised protocol; however, the issues arising from the use of induction drugs are not covered in the overall recommendations. We can see from the cases in Portlaoise hospital that a major issue was the pumping of induction drugs into the mother's blood stream, even when the baby was showing signs of foetal distress. These drugs make the contractions more frequent and stronger, putting too much strain on the heart of the little baby. That is a concern that I would like to see addressed.
In reply to Deputy Caoimhghín Ó Caoláin, the Minister has said 38 midwifery posts were approved. When were they approved? At what stage of the recruitment process are the approved posts? At this time do we have sufficient midwifery staff in Portlaoise hospital such that I, as a local Deputy, can assure constituents that it is a safe hospital?
I thank the Minister and his team for coming to the joint committee. I very much welcome the recommendations made in the report and the speed of Dr. Tony Holohan in compiling it. The content is not surprising and, in essence, what the families concerned have been seeking. It is meritorious and the recommendations must be implemented in full. The concern of everybody in this room is the potential lack of confidence that all of these recommendations will be carried out. As the Minister said, reports have already been compiled on these specific cases, but they were concealed or kept from the families. They make for shocking reading. I have looked at the desktop incident review form for one of the babies. The parents were told it was a stillbirth, but the resuscitation of the child had been discontinued at 22 minutes. It is difficult to have faith in the capacity of the Department of Health and the HSE to fulfil its commitments and the proof of the pudding will be in the eating.
The Minister referred to recommendation No. 11, the new national patient safety surveillance department, which I know Dr. Holohan has strongly recommended. One of the current concerns that I share with the families is that it will be dominated by high level staff in the HSE who have already failed in their duties. It is important that there be a strong degree of independence in order that patients throughout the country can trust in the process. That is very important, both for the parents and the public at large.
I am a little bemused by the assertion that we can continue to have full faith in the perinatal fatality figures, while at the same time accepting that the documentation and the collation of the figures have been flawed. The process has been flawed. When babies who have died are not recorded, that is a flawed system. I worry when I hear assertions being made by delegates before the committee that the statistics overall will not change and that we will continue to be one of the safest providers of maternity services. It is important to acknowledge that we do not know this.
Professor John Crown has described the ridiculously low level of consultant posts. That does not only affect maternity services; it also affects services across the board and this must be acknowledged.
I must accept the Minister's sincerity. He expresses regret and remorse and there has been tear shedding in the past couple of weeks in the Dáil Chamber, at the committee and elsewhere in the past. The reality is that senior figures in the HSE and the Department of Health were well aware of this issue having been approached by and met family members but nothing happened. The Minister has spoken repeatedly about accepting responsibility for the delivery of health services, saying the buck stops with him. I find it hard to reconcile that senior figures in the Department and the HSE were approached by and met the families, yet none of these staff brought the issue to the Minister's attention. Is that acceptable when the buck stops with him?
I am not a member of the joint committee and appreciate the opportunity given to me as a public representative in County Laois to discuss this issue. I thank the Minister for his input. He is dealing with the issue in an upfront and proper manner. I have never spoken to Dr. Tony Holohan, but I admire his report. It is good to see a professional public servant giving a hard hitting report. Let it offend those whom it has offended because that is how it has to be. It is a template for how issues in the public service should be dealt with.
We offer our sympathy to the families concerned. Their courage in coming forward must be admired. Given that these issues were well known at senior levels in the HSE and the Department of Health, did it take the television programme "Prime Time" to embarrass somebody into doing something about them? Are other issues, known at senior level, not being dealt with? Will the Minister comment on how the staff dealt with the inquests? There are issues about evidence given at inquests. I am sorry if this point was made earlier.
We all agree that we hope this will be automatic, but it is not automatic in the way the public service works. The families have been through enough. Should these cases go before the State Claims Agency? I hope the Minister will instruct the agency to settle them and not drag the families through the courts. The HSE has a legal team, the sole function of which is to get cases into the legal process. There should be no further torturing of the families. If the cases go to the State Claim Agency, please do not drag the families through the legal process, as they have been through enough.
Deputy Brian Stanley referred to non-nationals returning to their home countries to give birth, the inference being that some maternity services are unsafe. I do not think the statistics, even though we have had a discussion on them, bear this out. As a doctor, I know there are many reasons people go back to their home countries to give birth, as they like to be near their parents, families and friends. That is not to say, however, that I am going to rely on statistics because they do not reveal incidents like the ones we have seen in Portlaoise hospital. I remind members of the best case involving the three-in-one vaccine in which some children suffered brain damage. Statistically, one could not prove the vaccine had caused the damage, but a whistleblower in the company blew the lid and told about the bad batch. When that batch was looked at, one was able to determine that it had been the cause of the problem. Statistics can only tell us so much. What else do we have to compare ourselves with other countries? We cannot use anecdotal evidence all the time; we need a much more sensitive measure to monitor what is going on in hospitals, not only in maternity services but everywhere else. We are developing such a measure through HIQA.
Deputy Brian Stanley mentioned an independent recommendation on the use of the artificial oxytocin hormone or Syntocinon, as it is known. Recommendation No. 20 is a national guideline on the induction of labour and should be developed by the HSE. That will be done.
Deputy Lucinda Creighton asked several questions. I am not happy as Minister for Health to take people's word; I need validation and evidence-based decision-making. The same applies to section rates, in respect of which there are significant variations. The Deputy may have mentioned the WHO rates for sections, but we must remember that the World Health Organization looks at all countries in the Third World, Second World and First World.
When I met the Institute of Obstetricians, it was at pains to point out that while the section rate worldwide was around 15%, that was not the case in First World countries such as Ireland. Here the rate is 27% or 28%, which still means that we have some hospitals that are outliers with rates of 38%. I want that matter to be investigated and a report on it.
Deputy Lucinda Creighton has mentioned the need for an independent body, which is referred to in recommendation No. 11. That monitoring is to be carried out by HIQA which, we would all agree, has been independent in the manner in which it has carried out its investigations in an even-handed way. I should take the opportunity to inform the committee that Dr. Tracey Cooper, the CEO of HIQA, is leaving to take up a new job in the public health sector in Wales, her home country. I wish her well and thank her for all of the work she has done in shepherding HIQA into the space it is in where it is considered to be fair, independent and unafraid to say it like it is.
I will let Dr. Holohan deal with the perinatal statistics. The Deputy asked if I considered it acceptable that complaints could be in the system for that length of time. I do not.
Deputy Sean Fleming asked if it had taken the "Prime Time" programme to prompt us into taking action. While I had received a letter in relation to an incident, when I watched the "Prime Time" programme and saw that there had been four or five incidents, obviously, we had to take action immediately.
I am aware that the Deputy was concerned about the inquests, an issue we have discussed here. The adversarial nature of inquests needs to change, as well as the expense involved. Sometimes parents have to dig deep into their financial resources to get through an inquest, given its adversarial nature. That is not right. I agree with the Deputy 100% in terms of the manner in which the HSE has historically dealt with some of these cases which continued for several years before then being settled on the doorstep of the court. There is a better way and we will have a better way because it is not fair that parents should have to remortgage their homes to get justice for their children.
Dr. Tony Holohan:
The Minister has covered most of the questions asked. I will deal with perinatal statistics and the flaws we found in the reporting system, an issue raised by Deputy Lucinda Creighton. It is not an assertion we are making. We have set out the actual gaps and their scale and what the differences or discrepancies are. There is a graph that shows we have a higher level of reporting and its quantity, if we were to define our perinatal reporting rate according to the definition we are recommending. That would allow us to say this is the impact we think it would have on our international league table assessment of our perinatal reporting rate. We know that there are variations in all reporting systems. I daresay that if other countries were to make the kind of analysis we have now made of our perinatal reporting systems, they would probably find similar weaknesses. There is an issue about comparing like with like when one gets into talking about the detail of perinatal reporting in different countries.
I think the Minister has dealt with all of the other questions asked, unless I have missed one.
Ms Laverne McGuinness:
Deputy Dan Neville raised a question on staff. The approval for the recruitment of the complement of 38 was given in July 2013. It also included approval for two additional shift leaders and a level 3 clinical nurse manager. A renewal campaign has been relaunched in the past couple of weeks and there is permission to recruit a greater number than 38, given the high turnover experienced. The director of midwifery, Mr. Ian Carter, as I explained to Deputy Caoimhghín Ó Caoláin, is also linking with the director of midwifery in respect of any other post required at Portlaoise hospital midwifery services. He is awaiting her advice and analysis of what else is required.
I am talking about the position around the country where the rest day has been withdrawn in some units but not all. I am asking that the issue be dealt with because the number of patients has increased but the number of consultants has not.
May I make one comment that I forgot to make? The issue of the number of consultants has been raised. I am aware of a report presented to me, which was out of date, which showed Ireland at the bottom of the list. In fact, in the Netherlands and Canada there are fewer obstetricians per head of population. They have developed new models of care, which is what we need to look at because it is not always about the number of doctors, nurses and the number of billions of euro spent. During a period of 12 to 14 years we saw a quadrupling of the health budget - I am not being political - which led to 569 patients being on trolleys on one day. We need to reform the system and look at the models of care in association and consultation with obstetricians and midwives to see how we can best deliver from what we all know is a very limited resource.
In the context of maternity facilities generally and also specifically in regard to Portlaoise hospital, is there a regular audit of facilities in dealing with adverse incidents and medical negligence claims and, if so, is there an average that is considered acceptable and an issue - I hate using that term - if the figure moves beyond that level?
Dr. Tony Holohan:
What happens is that all adverse incidents are the subject of reports. They are completed and sent to the State Claims Agency which makes them available to hospitals. I know that the agency has participated in some learning and feedback arrangements to obstetric units, particularly where there are concerns about the levels of obstetric claims generally, as a way of trying to extract learning from adverse incidents. We know that the level of reporting is variable as between services and professionals. Frankly, in general terms, nurses are much better at reporting than doctors who are not necessarily always good at reporting comprehensively on adverse incidents. We have made a recommendation in the report which the HSE has accepted and is in the process of implementing, that what are called "never events" become the subject of mandatory reporting to both the national director of quality and patient safety and the HSE and HIQA. Therefore, it will create visibility immediately around the serious events that we saw in Portlaoise hospital, the six about which we have spoken.
I thank the Minister, Dr. Tony Holohan, Ms Kathleen MacLellan, Ms Laverne McGuinness, Mr. Ian Carter and Mr. David Walsh for their attendance. In particular, I compliment Dr. Holohan on his report and the level of detail contained in it and the prompt manner in which it was produced. As a committee, we will return to the issue of maternity services later in our work programme. On behalf of the committee, I sympathise with and apologise to the families on the loss of their loved ones. It was a dark period in the health service which I hope will never be revisited by any family. I hope the culture of communication for which we all strive will be more humane and that no person or family will ever have to undergo what happened to the families in this case. I join the Minister in thanking Dr. Tracey Cooper for her work and congratulate her on her new post. We received a communication yesterday that she was leaving.