MOTHERS WHO LOST children at Portlaoise described being reprimanded for crying on wards for fear they would upset other patients, said one of the the three person investigation team who carried out the Health Information Authority report (HIQA) into Midland Regional Hospital.
Margaret Murphy said others described being handed their child’s remains in a tin box.
She says that the women did not have unrealistic expectations of the HSE.
“To err is human, but to cover up is inexcusable and to refuse to learn is truly unforgivable.”
The HIQA report comes after an RTÉ Investigations Unit report last year into the deaths of five babies at the hospital.
The report examines the six-year period up to 2012.
The release of the report was called in to question following the threat of legal action by the Health Service Executive. However, it is believed that the report published today has not changed its core findings.
This evening, Health Minister Leo Varadkar told RTÉ that some services at the hospital – which do not have enough patients to support them – will be discontinued.
The report finds repeated failures and non compliance in National Healthcare Standards by both the hospital and the HSE.
Patient complaints
HIQA finds in October 2014, a total of 176 complaints or contacts were made by patients.
While these cases involved a number of hospitals, the vast majority of them related to the maternity services at Portlaoise Hospital.
HIQA’s Chief Executive Phelim Quinn states:
This care fell well below the standard expected in a modern acute hospital. We would particularly like to pay tribute to the patients and families who made contact with the Authority to outline their experience of care within Portlaoise Hospital.
HIQA says the failures at the hospital have occurred “over a number of years by the HSE at a national, regional and local level”.
It states there are numerous clinical governance and management issues, which impacted upon the quality and safety of services provided at Portlaoise Hospital.
Patient experience
Central to this HIQA investigation was the experience of a number of patients and families whose experience of care “fell well below the standard expected in a modern acute hospital”, said the report.
When the investigation started, HIQA was contacted by 83 patients and their families, most of whom had used the maternity services at Portlaoise Hospital.
The investigation found there was an increasing pressure on the maternity services at Portlaoise Hospital as far back as 2004.
Parents who spoke with the Investigation Team gave examples of poor communication with hospital staff where they were not afforded adequate explanations following an adverse event including the death of a baby or regarding
their clinical condition.
Some parents said they felt that they were not entitled to an explanation.
Others said that unexplained medical jargon left them feeling intimidated and unclear as to what was being said.
Parents found that such lack of openness in providing information and explanations compounded their feelings of fear and grief.
Parents also described significant delays in the time it took the HSE to respond to their requests for information and explanations following adverse events.
Some women that the volume of the alarms on their cardiotocograph (CTG) machine (a machine used to record baby’s heart rate while the baby is still in the womb) were turned down or silenced.
Two of these women told investigators that some staff had shown them how to silence the alarm.
Made feel like a “naughty child”
One woman reported experiences reflected a lack of compassion, humanity, dignity and respect during her care. Another woman recounted that some staff made her feel like a “naughty child” or that she was a troublemaker when she questioned her care and treatment.
Another believed she was made to feel guilty for her tragic outcome and consequently this made her fearful of conceiving again.
One set of parents also said they felt that they were not entitled to an explanation
as to what happened when their baby had tragically died.
Others described being told their baby did not survive, or being given other sensitive information, in an unsuitable environment such as the hospital corridor.
There were also conflicting reports about when some babies had died.
Some parents reported that they were told that their baby had been stillborn or
that their baby had died instantly at birth. However, by obtaining documentation
or reports after the birth of their baby they subsequently discovered conflicting
information about when their baby had died.
Two sets of parents also reported being unprepared for seeing their deceased
babies.
“Grossly inappropriate”
The manner in which these parents received their babies was recounted
by them as being “grossly inappropriate and extremely traumatising”.
They stated how their baby was brought to them in a metal box on a wheelchair
covered with a sheet and pushed by mortuary staff.
One mother described how the box was not of sufficient size and their baby was squeezed in to fit. She said she did not remove or hold her baby for fear of being unable to return him to the box. One woman stated that she had been told that this arrangement was
intended to prevent upsetting the other mothers.
The experiences described by parents highlighted an apparent lack of skill and sensitivity among some staff.
The parents of one the babies who died, Mark and Roisín Molloy, lost their son Mark 22 minutes after his birth in January 2012.
An inquest into his death took a jury just five minutes to rule it as a case of medical misadventure. Since then, the parents continually called for an inquiry into the services at the hospital.
The Minister of Health at the time, James Reilly, promised to get answers.
No meaningful oversight by HSE
The report is also highly critical of the HSE as a whole, stating:
… there was no evidence that the HSE nationally was proactively exercising meaningful oversight of the hospital and the inherent risks there. Up until the publication of the Chief Medical Officer’s report in February 2014, it appeared that senior HSE managers were predominantly focused on controlling healthcare expenditure.
HIQA states that there is no evidence that even after the RTÉ investigation that patient safety issues were high on the agenda of senior HSE management.
Up until late 2014, patient safety issues were not a standing agenda item for discussion at
meetings of the Health Service Directorate, the highest level of management within
the HSE.
Despite the seriousness of the patient safety concerns at the hospital at
the time of the Prime Time programme, there was no evidence that key senior HSE managers had visited the hospital in the immediate aftermath of the broadcast to assess the situation in the maternity services.
Following the RTÉ Investigations Unit’s Prime Time programme in January 2014,
relevant minutes from regional quality and patient safety committee meetings
held during February 2014 were acquired for the investigation.
The investigators found the minutes do not detail any remedial action at regional level to
either deal with the issues raised in the television programme or to support local
managers in dealing with its aftermath.
HIQA said that the HSE was aware of risk management deficiencies at the hospital, but they were not actively addressed.
In December 2012 the Authority raised with the HSE the immediate requirement to appoint an experienced and qualified risk manager to the hospital. However, this did not happen.
‘Significant service failures’
Quinn states:
“It is notable that local and national HSE inquiries and clinical reviews into patient safety incidents and significant service failures in Portlaoise Hospital were also carried out.Had the findings and recommendations of these inquiries and reviews been attended to, the Authority believes that the risks to patient safety and service quality could have been substantially reduced.
The report recommends that an independent patient advocacy service be set up to ensure that patients’ reported experiences are recorded, listened to and learned.
Other concerns
The HSE itself in 2012 and 2013 had specifically identified clinical risks associated with surgery and emergency medicine, going as far as to say that surgical services at the hospital should cease.
However, at the time of publication of this report, the hospital continues to deliver these services.
Martin Turner, head investigator into governance says that Portlaoise has “clear direction” and has been in limbo because it is under resourced.
Professor James Walker says that the hospital is safe for the majority of people and is getting safer, but in the past didn’t have structures in place to deal with elevated risks.
HIQA has called for a national maternity strategy must be developed and published as a matter of urgency. The Authority will appear before the Committee next week to discuss its report.
HSE response
In a press conference following the HIQA event, the HSE’s Tony O’Brien said that the executive is taking the report seriously, but that it was “too early” to talk about accountability.
He said that there were serious concerns about unfilled posts, one in six of which have not received a single application.
When it was put to O’Brien that the deaths of the babies could have been avoided, he accepted that was a “very serious finding”.
“Hands up, no arguments.”
Additional reporting Paul Hosford
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