Simon Harris (Wicklow, Fine Gael) | Oireachtas source

I welcome the opportunity to update the House on the Portiuncula University Hospital Health Service Executive, HSE, review of the maternity services and of a known number of adverse events between 2008 and November 2014, also known as the Walker report.

I would like to begin by expressing my deepest sympathies to the families involved and welcome the completion of this review for them. I also thank them for their engagement in the review process, which was so important. The review was carried out by an external clinical review team led by Professor Walker. The learning from this review will help with the development and delivery of maternity services in the future.

The Walker report has two parts. First, it provides a review of the maternity service provided by Portiuncula University Hospital, which is part of the Saolta University Health Care Group. Second, it reviews the care 18 babies and their mothers received and presents the overall findings from across these cases.

I wish to recall what happened in Portiuncula University Hospital, how the issues came to light and how my Department and the HSE responded. Portiuncula University Hospital provides maternity services alongside general hospital services. It is a model 3 hospital providing 24-7 acute surgery, acute medicine, critical care, emergency department and maternity services. In 2017, there were 1,668 births. The maternity department comprises 33 beds and four delivery suites.

In 2014, six babies were referred from the hospital for therapeutic hypothermia, also known as head cooling. This is used to try to reduce adverse effects from a lack of oxygen to a baby’s brain at the time of delivery. The hospital considered that six babies being referred for head cooling was higher than expected and, in November 2014, a preliminary review of these cases was undertaken by the hospital. This preliminary review found a cause for concern in the management of labour in some cases. As an immediate action, Portiuncula University Hospital agreed, and put in place, corrective actions and protective measures, including a process for the ongoing monitoring of all deliveries. The hospital undertook an audit the following month, in December 2014. This was to assess whether the recent changes were effective. The audit confirmed that all protective measures had been fully implemented and provided assurance that the services in place were safe.

Following the preliminary review, an external review was commissioned by the Saolta University Health Care Group in February 2015. The purpose of the review was to provide a general review on maternity services and to consider the care provided in the individual cases. The external review team was set up to operate to a number of terms of reference. These terms provided for a review of the maternity services in general and a review of the individual cases. In early 2015, an expert review team of seven members was established. This was chaired by Professor James Walker, professor of obstetrics and gynaecology from the University of Leeds. The membership comprised two obstetricians, two midwives, two neonatologists and a patient advocate.

At the commencement of the review the external team established a patient helpline for families who may have had concerns about their care. As a result of this, an additional 12 cases involving ten families were identified. In addition to the six babies covered by the preliminary review, the final external review covers the care provided to 18 babies and 16 families. I am assured that throughout the review process the HSE communicated with and met families and offered any services that they required to support them in dealing with the issues that arose. The review commenced in April 2015 and each case had an individual systems analysis conducted to identify the care received. These individual reports were provided to the families in April 2017.

I turn to the report's findings. I wish to extend my sincere sympathies and thoughts again to the families impacted. I thank them sincerely for coming forward, sharing their experiences and inputting to the review. By outlining those experiences, bringing their stories forward and demanding change, they have helped us to try to improve our maternity services, leading to the improvements that have been put in place. The clinical review team found that of the 18 cases reviewed, serious errors in management occurred in ten. The team considered that if those errors had not occurred, there would probably have been different outcomes for those babies. To recognise the trauma and hurt for the families, I will record for the Dáil the outcome for the babies involved. There were three stillbirths, three baby deaths, two babies with developmental delays, four babies who have ongoing issues and six babies who are considered to be doing well.

We cannot underestimate the extent of the impact of these events on the families, relatives and communities involved. It is important that the learning from the report and the experiences of these families should be a driver for change across all our maternity services in order that we can improve the experience of women and families as we go forward with our maternity services. To distil the learning, the report identifies a number of causal and contributory factors which affected the care received. The findings encompass a number of key areas, including lack of appropriate staffing, training across the multidisciplinary team, provision of clinical care, slow recognition of maternity incidents, communications with families, lack of open disclosure and lack of bereavement supports.

Important recommendations were made and I will outline some of them to the House. There were 35 key recommendations in total and the HSE has been asked to address them as a matter of priority. The recommendations include changes related to the care environment, training, provision of clinical care, staffing and improvements needed to deal with communication. The report outlines the need for the maternity services to respond to increasingly diverse and complex population needs to provide safe, evidence-based, accessible care to all women, babies and their families. It also highlights the need for maternity networks supported by effective leadership, management and governance arrangements. These are recommended to share expertise across maternity services. Data collection and use of information to detect patterns and ensure ongoing review of care provided are highlighted. Recommendations are made on the changes to how maternity services are staffed, the skill mix used and priority areas for training in order that maternity services can respond to increasingly diverse and complex population needs to provide safe, evidence-based, accessible care to all women, babies and their families.

We clearly need action on foot of this review. I have been advised that Portiuncula University Hospital has an implementation team in place to progress the recommendations and that most of the actions have been implemented. I thank the local team that has been working on this. Local Deputies will be aware of the work that has been ongoing to ensure the recommendations are implemented. Some of the key changes at the hospital include additional staff and a number of senior appointments. A director and assistant director of midwifery were appointed in 2016 and the number of consultants has increased to five from three. In addition, I am advised that training on open disclosure, CTG reading and relevant clinical issues has taken place in the hospital. I particularly welcome the fact that the implementation team includes input from some of the families affected. The implementation team must involve the families to drive the changes. That is important to ensure the findings of the review translate into meaningful improvements in care as experienced by the patients in the service.

Finally, I refer to the ongoing work being undertaken at national level to facilitate the provision of a consistently safe and high quality maternity service. Ireland's first national maternity strategy was published in 2016. It is incredible we did not have such a strategy until 2016. That probably gives us an insight into how maternity services were, perhaps, the Cinderella of our heath service. I am pleased that the previous Government delivered the first strategy. It is important and it enjoys widespread support across the House. However, it is no good having a strategy if there is no forum in which to implement it. The HSE national women and infants health programme was established in 2017. The programme is entirely dedicated to women and infant health care, delivering the national maternity strategy and driving improvements in maternity services nationally. The programme has published its implementation plan and is currently overseeing the establishment of maternity networks, an issue that arises in the Walker report, in all hospital groups.

Lessons have been learned from a difficult period in our maternity services, and the lessons that need to be learned have been identified. A number of changes have taken place in Portiuncula University Hospital, as I outlined earlier, but clearly the lessons from there must also be learned at national level. It must be about delivering the national maternity strategy and applying the lessons across the health service in terms of staffing levels, training for staff and the development of the maternity networks. Today's debate is a timely opportunity to reflect on the progress that has been made to date and to note the further steps that must be taken.

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