Tuesday, 30 September 2014
Topical Issue Debate
This issue arises on the back of the tragic and unnecessary death of Dhara Kivlehan which really saddened people throughout the country. She was a young woman in her prime and had just given birth to her first baby. The real tragedy is that this was not an isolated incident. Unfortunately, Dhara was the latest in a long list of others, including Savita Halappanavar, Nora Hyland, Bimbo Onanuga and Tanya McCabe. There have been inquests in Sligo and investigations in Portlaoise, in the middle of which are women hoping their giving birth to their children will be a joyous occasion.
All of the occurrences in question happened under the watch of the HSE. There is a systemic crisis in maternity care, for two reasons. First, the cutbacks have meant that not a single maternity hospital is operating to safe ratios. Critically, however, our policies are wrong. We have an outdated antenatal policy that has not been changed for years. We should be seeking to develop a country-wide strategy involving midwifery-led units; instead, the HSE is actively pursuing midwives. I find it sickening that on the same day that the verdict of death by medical misadventure was given against Sligo hospital, where a midwife said she could not tell a patient had jaundice because she was Indian, an independent midwife with 31 years of stalwart experience, Ms Philomena Canning, had her State indemnity insurance withdrawn consequent to a decision handed down in the courts. All afternoon I have been receiving e-mails from people who worked with Ms Canning and women for whom she acted or has been acting as midwife. Her crime was not killing somebody or doing something which led to somebody's death; rather, it was that, while observing all procedures and protocols, she transferred a woman to hospital after a home birth when that woman felt dizzy. That woman was discharged ten hours later and she and her baby were fine. Owing to the actions of the HSE, there are ten women – many of whom are about to give birth imminently – who do not have a midwife. This is really serious, particularly when one notes the list of fatalities in hospitals under the direction of the HSE. Nobody was suspended, let alone fired. Ms Canning has devoted her life to women and proper birthing in which women have a choice. The policy is completely wrong and the Minister must consider a decent and proper system of maternity care.
I extend my deepest sympathies to Mr. Michael Kivlehan and his family on their tragic loss. Mr. Kivlehan's perseverance in having the hearing held in the Republic did the State a great service in the sense that it has brought to light some of the issues regarding the death of his wife, Dhara. It was unacceptable in first instance that efforts were made not to have an inquest. It was said the inquest should be held in Belfast because that was where Dhara had died, but, thankfully, through the perseverance of Michael, his family and legal representatives, an inquest was held here. The information that has emerged on the care offered to Dhara in Sligo leaves a lot of questions unanswered on the longer term issues concerning maternity services, not only in Sligo but also across the country.
Ms Eilish O'Regan wrote an article in the Irish Independenttoday on the lack of information emerging from maternity services. We have raised this issue before on foot of the cases of Tanya McCabe, Savita Halappanavar and others who died while giving birth or just thereafter. Ms O'Regan states:
The blunt statement was made by Phelim Quinn, who is now acting head of the Health Information and Quality Authority (HIQA), when he was launching its report on the death of Savita Halappanavar in University Hospital Galway. He revealed that some maternity units have not even provided annual reports to give basic statistics and reveal how and why any babies or mothers died in their care. Maternity services have existed largely under the radar until the case of Savita and earlier this year revelations of four similar baby deaths in Portlaoise hospital since 2006. The full details of the tragic case of Dhara Kivlehan, who died in Sligo General Hospital, would probably never have come to light had it not been for her brave husband Michael.In general, we have very safe maternity services in this country, but there is still a problem regarding the collation of data on incidents and ensuring monitoring and proper oversight. We cannot continually blame staff when there are huge pressures on the system. There are systemic failures in the system regarding intensive care beds. A lack of such beds was identified during the inquest. We do not yet have a centralised system for intensive care bed allocation such that patients can be transferred to the place where the most appropriate care is available. We owe it to Dhara and the other women who have, unfortunately, died tragically to put in place safe services. Most important, we owe it to those women who are pregnant and the young women who intend to have a child at some stage in our maternity services. We also owe it to the staff.
I thank the Deputies for raising this important issue and allowing me to address the House on the matter.
I offer my deepest condolences to Mr. Michael Kivlehan, his son, Dior, and their families on the sad and tragic loss of Dhara Kivlehan. I understand the HSE has offered sincere condolences and apologised to both families for the shortcomings in the management and care of Mrs. Kivlehan at Sligo Regional Hospital.
While cases of medical misadventure do occur in the health service, it is very important to reassure women and their families that maternal and perinatal health statistics indicate that Ireland continues to be a very safe country in which to give birth. Our safety record and maternal mortality rates compare favourably with those of other developed countries. It is important that we reassure people of these facts.
The tragic death of Mrs. Kivlehan took place in 2010. This was before the investigation by HIQA into a maternal death in University Hospital Galway and prior to the CMO's report on perinatal deaths at the Midland Regional Hospital Portlaoise. The actions required to address the recommendations of both reports are being undertaken across health services to improve patient safety and provide a more patient centred model of care.
A patient safety culture is now embedded in the HSE's service plan through specific measures, including performance indicators for health care associated infections, medication safety and implementation of early warning scores, which did not obtain at the time. My officials meet the HSE each month on the service plan and patient safety is a standing item on the agenda. The HSE has advised me that improvements in patient safety continue within maternity services at Sligo Regional Hospital. The HSE is also focused on delivering improvements in the way critical care is organised and delivered within the hospital group structures to ensure patients receive the same high quality of care no matter where they are treated.
Furthermore, as the Deputies will be aware, we are working on the development of a new maternity strategy for Ireland. Developing the strategy will provide us with an opportunity to take stock of current services and identify how we can improve the quality and safety of care provided for pregnant women and their babies. This will include both hospital and home care and obstetric-led and maternity led units. The strategy will ensure services comply with best available national and international standards. We want to make sure women are provided with the right care, in the right setting, by the right person, at the right time.
While maternal deaths in Ireland are rare, I know that is of no consolation to those families who have suffered such a loss, but I can assure them that we are learning from mistakes of the past, building on that knowledge in the present and endeavouring to ensure they are not repeated in the future.
Deputy Kelleher Billy asked about the availability of intensive care beds. I asked for a report on this issue this morning. I also checked how many intensive care unit beds were available this morning as a random test and at least two were available. However, it may be the case that availability presents a difficulty from time to time.
Deputy Clare Daly raised a separate matter, relating to Ms Philomena Canning. I understand this case has been in and out of the courts for some time. As I have not been fully briefed on the case, I do not want to comment on it, as I do not know all of the details of it. However, I am aware that the HSE supports and provides cover for a number of community midwives and that no effort is being made to reduce or remove cover for all community midwives. I suggest that if the HSE has decided to withdraw cover in the case of this individual midwife, there may be a reason for it.
I appreciate the Minister's comment that he has not been fully briefed on the case, but I ask him to look at it because the reason is as I outlined, that she referred somebody to a hospital. This woman has an impeccable record. Sadly, the antics of the HSE have left ten women who are due to give birth imminently without somebody to assist them. I received many e-mails on this issue, but one I received this afternoon came from a woman who was a patient of Ms Philomena Canning and is 32 weeks pregnant. She says women are entering hospitals and leaving in coffins and that women are leaving maternity hospitals carrying their dead children home to be buried. She mentions that nine staff were found to have a case to answer in regard to the death of Savita Halappanavar but not one was suspended, never mind fired. All of them are still practising. She refers to inquests in Sligo, investigations in Portlaoise and says this is what the HSE calls care. She goes on to say: "I would rather birth on the side of the road than enter an Irish hospital as a pregnant woman."
The right to bodily integrity and make a decision on when and how one wants to have children is and should be at the heart of a proper maternity care system. I suggest the Minister should review this issue because there has been a deliberate undermining of community midwives. I know that he is only new in the Department, but I ask him to look at the case mentioned in order to help women at the coalface on this issue.
The Minister referred to the maternity strategy being brought forward. I am aware that there were concerns expressed about a strategy published, or partially published, for the north west, which has now been included in the overall national strategy. Whatever comes about, the key issue is that while we must have certainty in so far as we can, women about to give birth or who will give birth in the future must have confidence in the strategy.
There is huge anxiety and concern at times of tragedy such as those mentioned, but by international standards we have a reasonably good maternity service. However, this does not mean that we cannot do more. We should not just leave the report to the memory of the Kivlehan family. It should be acted on and any deficiency raised in the context of the inquest should be acted upon. While we are waiting for the maternity services report, some improvements to enhance the quality and safety of the service could be made. The pressures on maternity services such as the lack of consultants and the pressure on midwives must be examined. Comparisons with international standards show that we are short staffed in these key areas of maternity services.
I do not want to get into the Philomena Canning case. It may well be that Deputy Clare Daly does not know all of the facts either. When the HSE withdraws cover from somebody, it tends to do so for a reason, not at the whim of an official. Without knowing the reason for the withdrawal, we should confine our comments on the matter.
I am probably closer to the Deputy on this issue than she thinks. Pregnancy is not a disease but a physiological condition and there is no reason women with a normal pregnancy should not have their baby delivered at home by a community midwife or in a midwife-led unit. Every pregnancy does not need to be dealt with by an obstetrician and this is the sort of issue the maternity review will consider.
Whether in the case of an obstetrician or a midwife, I put it to the Deputy that the HSE does not withdraw cover lightly or on a whim but for a reason.
On the matters raised by Deputy Billy Kelleher, I inform him of changes that have been made since 2010 when the case occurred. The national early warning score has been introduced to detect deteriorating cases; in the hospital in Sligo there is now a new structured hand-over meeting between medical staff when they move from one shift to another and there is an enhanced and updated admission and discharge policy for ICU. With these changes, there are continuing developments in risk management, structures and processes.
While I believe we need more obstetricians - 120 is not enough - according to the OECD's report, Health at a Glance 2013, we have more obstetricians and gynaecologists per head than in Canada and New Zealand. The report also indicates that the ratio of Irish midwives stands above the OECD average and above that in France, Germany and the Netherlands. People can be quite selective when they make comparisons. They pick the countries with which they want to compare. I am picking countries with which I want to compare.
As somebody who has worked in eight hospitals, including a maternity hospital, I believe it is important to point out that being short staffed should never be an excuse for medical negligence or misadventure. It takes 30 seconds for a laboratory scientist to ring a ward with a blood result about which there is concern. It takes about one minute to check a blood result. If one misdiagnoses an acute abdomen case, it has nothing to do with time or resources, but is a mistake. We should not allow people to claim that being short staffed is an excuse for medical misadventure or negligence. It should never be accepted as an excuse. If we accept that excuse, it will always be the excuse. Today I heard the suggestion that a patient's mouth was taped with surgical tape because a hospital was short staffed. That is not good enough.
The Minister for the Environment, Community and Local Government is not available today to deal with this issue. I ask that the issue be referred back to the office of the Ceann Comhairle for a date to be provided that will suit the Minister, the Ceann Comhairle and me.