Clare Daly (Dublin North, Socialist Party)
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Question 109: To ask the Minister for Health and Children if he will outline the 11 recommendations made in the investigation into the death of a person (details supplied) and the reason three of the recommendations have not yet been implemented over a year after the death. [13155/11]

James Reilly (Dublin North, Fine Gael)
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This case was investigated under the National Incident Protocol by the HSE, using the Investigation Procedure and Toolkit to identify factors that contributed to this maternal death. To address these contributory factors and to prevent future harm arising from them 11 actions were recommended.

Recommendations were made in relation to the need to identify clinical pathways for the management of such cases.

The recommendations are as follows :

1. The need to identify clinical pathways relating to management of women with an intrauterine death in third trimester to complement existing medical management policy.

2. The Guidelines for Medical Management of Intrauterine Death should be revised in line with a review of the medical literature.

3. Details of all patients for Induction of Labour, regardless of place of induction should be centrally documented.

4. This recommendation cannot be disclosed as it contains personal, private, sensitive and confidential information relating to the individual patient.

5. Develop a brief operational outline of the Gynaecology Department to assist staff who are sent there on an occasional/intermittent basis.

6. Due to the complexity of work, there is a need for an updated training needs analysis of all midwifery and nursing staff on the gynaecology ward.

7. There should be a designated individual with responsibility for coordinating, monitoring and auditing the Basic Life Support attendance and Advanced Life Support Skills attendance, ideally a designated Resuscitation Training Officer.

8. An Obstetric Early Warning System should be introduced and evaluated.

9. Install additional phone lines in the ward.

10. A review of the possibility of emergency call bells or designated phones for emergencies in each room should be carried out and measures taken to address this.

11. Hospital wide analysis of all doorways in clinical areas to establish the feasibility of moving a bed in a critical event.

I have been informed by the HSE that all but the 7th recommendation have now been implemented. Discussions are under way in the HSE to bring the implementation of this recommendation to conclusion.