Alan Kelly (Tipperary, Labour) | Oireachtas source

I welcome the publication of the clinical review of the maternity services as Portiuncula hospital and this opportunity to discuss its findings. I commend the families who came forward, some of whom I know and have met. They are very brave. They are not happy with this report and they propose to continue the fight because they do not believe it goes far enough in terms of addressing the appalling experiences many of them had at the hospital. Like everyone else, I extend my sympathies to the families and extended families affected by this scandal. Following on from this report, lessons must be learned.

This report is a damning indictment of the manner in which we have treated women in this country. Publication of this report went below the radar because of the time at which it was published. I share Deputies' concerns in this regard. This report was long delayed. I met the families who told me they had seen the preliminary version, and although they were not happy with it, they knew it was ready to be published. This report was published at the time of the referendum and the CervicalCheck scandal, so it did not get the attention it deserved. The Minister might want to explain why that happened because people are coming up with their own answers as to why it happened.

I have spoken to the families affected and they are not happy with some of the report, though they accept other parts of it. No amount of apologies from the Saolta University Health Care Groupwill be of any comfort to them because the State let them down. It let down people who are very vulnerable and who suffered. One of the families, which I will call "D and C" and with whom I have had communications on a number of occasions, feels the review was inefficient. They said they would like to highlight the lack of efficiency in the review, question the method and independence of it and question the group, particularly as much of what was going on at times reached the media before it reached them.

The report was due originally in the summer of 2015 and has taken almost three and a half years to complete. This has added enormous suffering to an already traumatic experience and it is unacceptable. The hospital group had many questions to answer in the time leading up to the report being compiled. At the time, however, it seemed more concerned about its public relations profile than the families at the centre of this, something which, I contend, mirrors what is happening with CervicalCheck at present. A lengthy list of the failures in the delivery of maternity services at PUH has been published. It makes for quite difficult reading. Serious errors of management occurred in ten cases that would have led to different outcomes. There was a lack of management, and the process relating thereto, and leadership.

In 2014, six babies were referred from the hospital for therapeutic hypothermia, which was considered a higher figure than average at the time. Therapeutic hypothermia, or targeted temperature management, TTM, is a treatment whereby body temperature is maintained at a specific level in order to improve outcomes following a period of reduced or stopped blood flow to the brain. Following this, there were an additional 12 cases and we know what happened as a result. The report represents a catastrophic failing and falls in line with other failures. I have a very important question for the Minister. The review has a specific timeframe but these issues did not appear out of nowhere. I know people who believe that there are issues in this hospital dating from before this timeframe which need to be reviewed. Will they be considered?

I will focus on a number of key points in what is a very detailed report. The clinical review team noted that a shortage in staff numbers, limited access to training and limited availability of resources impacted upon the ability of PUH to keep up to date with some of the latest developments in skills and techniques in clinical care. The clinical review team also noted, from interviews relating to the 18 system analysis investigations, SAIs, and PUH training records, that the experience, level of ability and training of some obstetric non-consultant hospital doctors was not at a level previously experienced, requiring greater senior support.

We are acutely aware of the ongoing crisis management in respect of staffing at the hospital and across Ireland. We discussed this recently in the context of the volume of number not on the specialist register who have been appointed to consultant posts. What happened in the case of Portiuncula also happened in the past, which shows where we are heading in respect of problems in the future. Such problems will be on a mass scale across many disciplines. If we are appointing people who are not qualified to take up roles and who do not have the experience, training or knowledge of dealing with cases, we all know where that will lead, not just in obstetrics but also in other areas.

The report is shocking and deeply worrying. Given that the hospital was aware of its shortage of staff, it is baffling that there was no autonomous midwifery to take on low-risk care independently. This could have taken the form of clinics, led by midwives, in intrapartum care in order to allow doctors to focus on cases where there was significant medical need. There was also a clear breakdown in organisational terms. It is nothing new to us to hear of the HSE breaking down in organisational terms. In 2008, the hospital was a stand-alone operation under the umbrella of HSE west and then became part of the group it is in now. The review is very critical of this, stating:

... senior staff at PUH did not feel involved and believed that they no longer had ownership of their environment. It is the view of the CRT that this may have contributed to PUH being less able to respond to the problems that arose at a local level. At the time of the 2014 cases, incidents were reported onto Q-Pulse initially by PUH staff. Preliminary Assessment Reports (“PAR”) were completed by PUH and forwarded to the Serious Incident Management Team “SIMT” meeting. There was no further action after the escalation of the first two cases

Why was this? It was because the structures of the HSE did not allow it and there was nowhere to go. This represent the complete systemic failure of an organisation.

It is extremely difficult to read all the clinical issues identified in the report. I welcome a number of recommendations relating to the care environment, training, clinical care, staffing improvements, the need for effective leadership, change in governance arrangements and data collection. We all know that open disclosure did not happen but there have been key changes, with additional staff in the form of a director and assistant director of midwifery and an increase in the number of consultants to five. However, we need to ensure that this report is implemented. We also need to ensure that, where there are other cases, they will be dealt with independently.

We also need to learn from this on a number of fronts. We have a national maternity strategy which, even as Opposition spokesman, I would say is brilliant but it is not being funded. A new hospital is required in Limerick but it cannot even get a couple of million euro for it to start. There are issues over neonatal brain injury rates. Are voluntary hospitals sharing their neonatal brain injury data with the HSE? Are there any outliers that we need to be concerned about? Evidence which has been sent to me suggests that there may be. Is there any resistance to data-sharing in this area? Does the national women and infants health programme have sufficient authority to oversee outcomes on behalf of the Department of Health? Are voluntary hospitals dealing with outcomes appropriately?

It would be wrong not to mention the correlation between the recommendations in this report and the Bill I introduced in the House yesterday. The Civil Liability (Amendment) Bill 2018 is a critical small piece of legislation based on the death of Conor Underwood, the son of Derek and Mignon Underwood, in Wexford General Hospital. Where a stillborn birth occurs, there is not the capacity for the family involved to seek redress. This is an anomaly and, in the context of the issues identified in this hospital, I ask the Minister to co-operate with the Department of Justice and Equality to ensure that it can be speedily added to another Bill.

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