Wednesday, 13 March 2019
Independent Clinical Review of Maternity Services at Portiuncula University Hospital: Statements (Resumed)
It is unfortunate that this has been sandwiched between the cervical smear scandal and Brexit. It is unfortunate for those people who have suffered dreadfully. I want to start by extending my sympathy to the families. Six babies died one way or another and a lot of other children suffered. On page 22 of the report, Professor Walker writes: "It is obvious to the [clinical review team] that this review process has taken a toll on both families and staff. It has taken a prolonged time of over three years and there are many reasons for that". Not alone did it take a prolonged time from when it was commissioned. It was commissioned in January 2015, it began in April 2015 and we are now in 2019, with the report sandwiched between these two topics.
The key findings have been set out in detail. Some 34 key points have been identified and 35 recommendations have been made. They are interconnected and come under various headings: environment, clinical staffing, communications issues, clinical governance issues and training. The question, of course, is how many have been implemented. When the Minister made his statement in June 2018, he pointed out that over 80% were implemented or in the process of being implemented. When the Minister of State, Deputy Michael D'Arcy, is ready, he might be able to confirm how many of those very important recommendations have been implemented.
In terms of the background to the report, it was commissioned following the reporting of the deaths of six babies referred for therapeutic hypothermia from Portiuncula Hospital in 2014. That cluster of cases, which was high, prompted an internal review. That was completed in December 2014 and led to a further external review because of the concerns raised. This has caused great distress to all of the people involved. The independent review started out reviewing six cases and when the communications started, a further 12 cases were added. In total, 18 cases were reviewed and of those 18 cases, serious errors were identified in ten of them. The report acknowledged that without those errors, there would have been a different outcome.
I will make some specific points about this and then move into the maternal strategy and general themes that are emerging in respect of maternity care in Ireland. It is upsetting to read the report, although it is set out very clearly. It highlights very basic absences and understaffing of both midwives and consultants.
It is important to place this report in context. It was examining a period from 2008 to 2014, which was a time of cutbacks and a time when we valued saving the banks far above saving mothers' and babies' lives. That has to be borne in mind all of the time when we look at these reports. In this report, the report into the death of Savita Halappanavar, the Portlaoise hospital report and many other reports, severe cutbacks in staff are identified repeatedly to the detriment of women's lives.
Not alone was there understaffing but there was also a lack of proper and adequate skills. There was a lack of multidisciplinary training. There were problems with governance. There were problems in simply reading cardiotocographs, CTGs. There was a problem in regard to communications between nursing staff and between nursing staff and consultants. There was a serious problem in regard to talking to the families and communicating with them. The same type of issue emerged in regard to cervical smears and in all of the other inquiries, particularly in respect of Portlaoise hospital.
I will quote from the report on the Midland Regional Hospital, Portlaoise, because it really captures this point. While there have been many reports into Portlaoise hospital, this report was given in February 2014 to the then Minister for Health, Senator Reilly. The overall conclusions stated:
1. Families and patients were treated in a poor and, at times, appalling manner with limited respect, kindness, courtesy and consideration.
2. Information that should have been given to families was withheld for no justifiable reason.
3. Poor outcomes that could likely have been prevented were identified and known by the hospital but not adequately and satisfactorily acted upon [and so on].
At that point in 2014, the report also concluded that "The external support and oversight from [the Health Service Executive] should have been stronger and more proactive, given the issues identified [way back] in 2007." That report was on Portlaoise hospital and dates from 2014. This report on Portiuncula Hospital is from May 2018 and shows the exact same problems were emerging.
I wish to place in context that I worked in Ballinasloe for many years and that Portiuncula Hospital had a very fine record. It was set up in 1945 and had a wonderful record until what happened. It went under the Western Health Board and subsequently under the group of hospitals known as Saolta. Saolta was put together haphazardly and without proper planning, as has happened with many other organisations. That has also been identified in this report on Portiuncula Hospital. Portiuncula staff felt completely marginalised, although on paper the governance arrangements were in place. Do I have five minutes remaining?