Wednesday, 13 March 2019
Independent Clinical Review of Maternity Services at Portiuncula University Hospital: Statements (Resumed)
I welcome the opportunity to speak on this topic. The report we are speaking about here, the external independent clinical review of maternity services at Portiuncula Hospital Ballinasloe, dated May 2018, has unfortunately been sandwiched between the cervical smear debacle and Brexit. It is most unfortunate. This debate started in June 2018, when the Minister gave his opening speech. We are now continuing with it in March 2019. This is most unfortunate. I understood that I had ten minutes. I am not sure how much time I have. This is a very serious matter.
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?
In regard to this matter, I seek some answers as to whether these 35 recommendations have been implemented. This report was published in May 2018. Where are we with regard to these recommendations? When the Minister spoke in June 2018, all of the recommendations had not been implemented. Second, he pointed out that the maternity strategy was very welcome, and I certainly agree with him. He pointed out that it was unbelievable that we did not have a strategy before now, on which I also agree with him also.
The national maternity strategy was brought into being to cover the period from 2016 to 2026. There are many recommendations in the strategy but I do not know if they have been implemented. For example, I understand there are midwifery vacancies in more than one area. I will not use the few minutes remaining to me to outline this issue but when a strategy is produced, there is a duty on the Government and on the Minister, when he speaks in the Dáil, to clarify precisely what has and has not been implemented and where we are going in regard to it. We must bear in mind that the national maternity strategy arose from the basic problems identified arising from the Portiuncula inquiry and, in terms of my own city, from the death of Savita Halappanavar, where a strong recommendation, among many other recommendations, was to have a maternity strategy. I welcome that and the fact that it will be woman and child-centred. There is a very good opening statement by the chair, whose name I have just forgotten, in which she refers to making the woman the centre of the process, as well as giving choices to women regarding where they give birth. She also refers to not medicalising something that is extremely normal, which is set out in the strategy, that having a baby is normal and that there should be a pathway of choices in that regard. Where are we in that regard? I have read the strategy to try to see where it has been implemented.
This is particularly poignant given that the independent midwife, Philomena Canning, is currently facing death, as she said herself. She is an independent midwife who fought bravely to bring choice to women in terms of where they would give birth. Her indemnity was withdrawn in 2014 by the Health Service Executive. As a midwife she delivered 500 babies. We know that; this is all factual. She had planned to set up a home centre in Ireland, which is what many women, including myself, would love to see, but her indemnity was withdrawn. Unfortunately, we did not have the national maternity strategy at that time, which sets out that aim as one of the ambitions to have in Ireland. That indemnity was subsequently restored to her but it was too late.
I am highlighting her case briefly because the woman is facing death. I do not want to dwell on it except to highlight that she and very many similar independent midwives have struggled to tell us there is a better way to allow a woman give birth than the medicalisation of that whole process. That was one of the key recommendations in the report we are talking about tonight. I refer to the patriarchal, hierarchal nature of the relationship between doctors and nurses in the hospital. Many times the midwives themselves reported that there was a lack of staff during that critical period and no action was taken on it.
I will conclude because I have to. That is not the Acting Chairman's fault but it has been difficult to follow the time in order that I could work my thoughts around what I was saying.
I welcome the opportunity to contribute. As has been pointed out, Portiuncula Hospital was opened in 1945. We have to be mindful of the parents who, unfortunately, did not have a good experience in the hospital and who lost their babies. We have to remember those tonight while we are having this debate.
On the other hand, two of my three children were born there and, thankfully, everything worked out very well.
The report outlined different actions which needed to be taken. My understanding is that many of those actions have been taken. I am aware that there is now joined-up thinking, which was not the case previously, and that Portiuncula is working in conjunction with the hospital in Galway, which is needed.
My sister-in-law had a child in Ballinsaloe at Christmas and the staff were excellent. There were a few complications and the child was brought to Crumlin straight away in order to ensure that everything was okay. We have to be mindful of the staff who work in Portiuncula because a shortage of personnel was highlighted for years and nothing was done. We need to compliment the staff who there on the work they are doing.
We must also be mindful of the needs of people in Roscommon and east Galway. Parts of Roscommon are 60, 70 or 80 miles from Galway hospital. Portiuncula Hospital is vital for maternity services and all the services available there, including accident and emergency. We need to ensure that resources are put into Portiuncula Hospital, that the staffing levels are correct and that the necessary infrastructure is put in place. There is supposed to be a building project in respect of the accident and emergency department. I hope that will not be left hanging for a while because of the debacle relating to the national children's hospital.
Things like this sometimes give a Government an excuse to state that it will move the hospital somewhere else. Figures were put out about the babies who were born in Portiuncula Hospital as against Galway hospital and suggestions were made that Galway hospital has better services. We need to ensure that those services are in Portiuncula Hospital and it is kept going because it is vital. I compliment the staff who work there, especially the nurses and midwives.
I thank the Deputies for their contributions. Following on from what the Minister, Deputy Harris, stated when opening the debate on this matter last June, I wish to express my heartfelt sympathies to the families involved and commend them on their engagement in the review process. It is vitally important, not least for those families, that the systems learn from these events and ensure that such learning is made available nationwide. More importantly, we must turn that learning into action. As outlined earlier, the HSE has been asked to progress the recommendations as a matter of priority and its work is under way. It is notable that the implementation team which has been put in place by Portiuncula Hospital includes some of the families involved. I have no doubt that the process will be strengthened and the output improved as a result of the participation of those families.
I reiterate the Government's commitment to the progress of developments of maternity care in Ireland. As the House is aware, Ireland's first national maternity strategy was published in 2016 demonstrating a new and enhanced focus on maternity care at both policy and service delivery level. The maternity strategy maps out the future for maternity and neonatal care to ensure that it will be safe, standardised, of high quality and offer an enhanced experience and more choice to women and their families. The strategy recognises that, while all pregnant women need a certain level of support, some will require more specialised care. Accordingly it proposes an integrated model that delivers care at the lowest level of complexity and encompasses all the necessary safety nets in line with patient safety principles. It aims to ensure that women and babies receive the right care from the right professional at the right time and in the right place.
In 2017, the national women and infants health programme was established to lead the management, organisation and delivery of maternity, gynaecology and neonatal services. This work includes implementing the strategy and overseeing the establishment of maternity networks nationwide. Previously the Minister outlined how these maternity networks are being established across hospital groups. In addition to supporting and strengthening small maternity units such as that at Portiuncula, this development will serve to improve governance and oversight and facilitate the sharing of expertise within and between networks. The establishment of a maternity network is currently being progressed within the Saolta hospital group and the first step of that network will initially comprise Galway University Hospital and Portiuncula Hospital.
The national women and infants health programme is delivering on the vision of the strategy in line with the detailed implementation plan which was published in October 2017. Development funds allocated to progress the implementation of the strategy since its launch in 2016 have ensured that progress has been made and that services have improved. With the €4.15 million that Government allocated to maternity in 2018, the national women and infants health programme addressed several priorities including improving quality and safety, establishing community midwifery teams and increasing access to anomaly scanning services. The further €1 million allocated this year will ensure the development of maternity services remains a focus with priorities for 2019 including the ongoing establishment of the maternity networks and expansion of the strategy's supported care pathway.
Other key building blocks which have been put in place to facilitate the provision of a consistently safe and high quality service include the HIQA national standards for safer better maternity services and the HSE national standards for bereavement care following pregnancy loss and perinatal death. These initiatives, along with the national maternity strategy, clearly demonstrate that, over recent years, very significant efforts have been made and improvements achieved through a continued focus on the progressive development of maternity services right across the country. The House can be confident that we are moving in the right direction and translating plans into actions for the 80,000 families who access maternity care each year.
I want to touch on a number of the issues raised about the implementation. Saolta hospital group has confirmed that 95% of the recommendations are complete or under implementation. In addition, significant work is ongoing on the establishment of a clinical network between Portiuncula and Galway hospitals. Arrangements have also been made to have a perinatal pathologist for the hospital group. The implementation of the recommendations of this report will be audited by Saolta hospital group this coming May, one year post production.