Martin Kenny (Sligo-Leitrim, Sinn Fein) | Oireachtas source

I offer my sympathies to all those women and families affected by the serious and scandalous errors which occurred at Portiuncula University Hospital and resulted in their babies dying or being left with life-changing injuries and disabilities. I thank Professor James Walker who led the expert review team and authored this report. While the report into what happened in the care of these 18 babies was much needed, it is a shame that such errors and poor care occurred in the first instance. As in the case of the report into baby deaths at Portlaoise hospital, this report highlights huge failures, some of which continue to exist in our health service. Historically, maternity care has often been underfunded, subject to poor medical practices and has been investigated continually as a result of neonatal and maternal deaths and injury.

Reports such as this report into Portiuncula hospital do not exist in isolation. They follow a pattern of poor care for women and infants in this State. It is not lost on the women of this State that not only do they receive inadequate maternity care, but even where care is given, there are significant problems due to understaffing, poor practices, inadequate equipment and a health service that is not sensitive to, and does not reflect, gender differences. In other hospitals, a 20 week scan is not standard procedure. This is a huge problem across many of our maternity hospitals.

The report criticises the hospital for poor communication among maternity staff and a lack of skills and training to deal with emergency cases. It found that there was a general lack of skills and training among front-line staff and a lack of obstetric consultant supervision in the labour ward. It also found that consultants appeared to wait to be called and did not take ownership of the clinical care being given, and this resulted in an inappropriate handover of care. The report also found that care when things were progressing normally appeared to be of a high standard but the response to a deteriorating situation was often slow and deficient. This appears to a trend across many of our maternity hospitals and general health services.

When one delves into the report and reads the testimony of those interviewed, one gets a feel for a hospital that was being neglected by management and plagued by difficulties in recruiting and retaining staff. During interviews, the obstetric consultants at Portiuncula hospital expressed to the critical review team their concern that the level of training and experience of some of the non-consultant hospital doctors, NCHDs, was not of a standard previously seen and that this was significantly compounded by the fact that there was an unfilled registrar training post in Portiuncula University Hospital, PUH, and that junior grades were often filled by locum doctors to cover registrar positions. Yesterday, Sinn Féin received a response to a parliamentary question from the HSE, showing that Portiuncula hospital spent €5.6 million on agency staff in 2017. This is reflective of a crisis in recruiting and retaining staff.

The result of the above problems at PUH was that doctors came with different levels of knowledge and varied knowledge of the Irish maternity system. The clinical review team, CRT, was also informed that there were no formal clinical assessments of new appointees and no increase in supervision by consultants as there were only three consultants to run the service. The CRT heard a lot of concerns from the midwifery staff who felt generally unsupported and that the midwifery management structure was fragmented. The midwifery lines of responsibility were very convoluted and midwifery staff levels were deficient, with a lack of consistent CMM cover in the labour ward. Midwives had requested more staff as early as 2013. As a result of these staffing deficits, there was a lack of support for junior midwives, and midwives said they sometimes found it difficult to escalate to an obstetric consultant.

The report found that in many instances systems failures, staff deficiencies, poor practices, a lack of training and skills among staff, particularly agency staff, and poor management and oversight played a significant role in the errors that occurred, which resulted in baby deaths or babies being left with life-changing injuries and disabilities. Such failings go to the heart of the problems and crises affecting the health service. Among the issues highlighted in this report are a recruitment and retention crisis, an underfunding of our maternity services, an over-reliance on agency staff, and a lack of appetite to implement the national maternity strategy and bring Ireland into line with Birthrate Plus standards and so on.

Another issue pointed to in the report was a lack of open disclosure of information to the family, an issue arising in so many other areas of our health services, as dealt with in this House in recent days. Even when information was provided, some of it was withheld and families told the CRT said that they only received information regarding events during delivery a significant time after the baby's birth, often weeks, months or years later. The CRT acknowledged that it is incredibly frustrating for families not to get important information about their cases in an open, transparent and timely manner. Time and again, such issues have arisen in our health service, including in the recent CervicalCheck scandal. My colleague, Deputy Louise O’Reilly, who cannot be here due to an engagement with survivors of the transvaginal mesh scandal, introduced a Bill earlier today to make open disclosure mandatory, not voluntary. This is a critical issue. The problems and hurt a lack of open disclosure have caused to the women and families affected cannot be understated.

The recommendations contained in this report and the national maternity strategy must be implemented as a matter of urgency. If these recommendations are not implemented and if the individuals and agencies do not take responsibility for what happened, these scandals will continue. There should automatically be an inquest into every maternal death, neonatal death or death of a baby during delivery. Deputy Clare Daly’s Coroners Bill provides for automatic inquests in all cases of maternal deaths in our hospitals. The Government refuses to progress this Bill. We need to see such legislation enacted as a matter of urgency.

I again offer my sympathy and the sympathy of Sinn Féin to the women, families and babies affected by this scandal.

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