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Things can and do go wrong in healthcare; the critical question for any healthcare organisation is how it reacts when things go wrong.
ON PAGE 58 of the Health Information and Quality Authority’s (HIQA) report into the safety and standards at the Midland Regional Hospital in Portlaoise is the sentence that encapsulates the whole report.
The report does not paint a picture of an endemically flawed institution, but one that did not have either the resources or know-how, or both, to deal with cases that went beyond the norm.
The reasons for this are debated. Governance expert Martin Turner said that he had “never seen an organisation as disorganised as the HSE,” saying that Portlaoise Hospital was either under-resourced for what it was being asked to deliver or over-valued for what it could actually achieve.
The HSE’s Tony O’Brien differed, saying that this was a case of resources. Speaking in a room overlooking Heuston Station some 90 minutes after the HIQA report was published on Friday morning, O’Brien talked about not being able to fill vacancies – figures show that one in six consultant jobs have received no applications whatsoever – , and of a health service changing and trying to get its house in order.
But, this was more than a failing of resources as Margaret Murphy, another of the HIQA investigation team said.
Resources don’t dictate whether a grieving mother is reprimanded for crying, or whether a child’s remains are stuffed into a metal box or whether the right time of death is given.
The report says that there were “opportunities to learn and change” which were missed and chances for this not to happen that were not taken.
Eight babies died
Following an RTÉ Investigations Unit report which aired on 30 January last year, the hospital set up a helpline for patients.
In the cases it examined, RTÉ found that “there were no congenital abnormalities, meaning the babies did not have a physical condition where their ability to survive was diminished resulting in death. Therefore other factors led to their deaths”.
The RTÉ segment was the catalyst for the 208-page HIQA report, but HIQA emphasises that this is not a resolution for the eight families who lost babies in avoidable circumstances.
A total of 83 patients contacted HIQA, some of whom described traumatic experiences while giving birth at the hospital.
Of those, the investigation team met with 15.
The patient experience
The HIQA team found that the experience of those 15 sets of parents was overwhelmingly negative.
Most parents recounted how difficult it was getting information and clarity on issues, they believed their questions were ignored and requests for meetings were avoided or refused.
Parents said that some staff were difficult to understand and possessed poor communication skills. This left parents feeling “intimidated”.
Women were not told about side effects of medicines and the volume on a machine to monitor heart rate was turned down.
Most parents told HIQA that staff were “uncaring” and didn’t listen. The lack of communication is called a “recurring theme” in the report.
As Professor James Walker of the investigation team said:
Portlaoise did not have a ‘phone a friend system’. There was a lack of teamwork and supervision. There was poor communication between staff.
Dignity and respect
In the section labelled “Dignity and respect”, the report outlines how parents who lost their children were treated.
The Investigation Team met a woman whose 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. This fear of further pregnancy was a recurring theme among those parents who met with the Investigation Team.
Doctors routinely didn’t address patients and some parents were told sensitive information in public areas. One set of parents were told their child had died in a public corridor.
There were instances where a single member of staff showed kindness, but this was not considered the norm.
The handling of bereaved parents was also criticised, with one woman saying she was “reprimanded” for crying and another given her child’s remains in a metal box too small for his body.
Another set of parents received a phone call years after the death of their child asking how they wanted retained tissue to be disposed of, despite not consenting to the tissue being kept.
This, said investigator Margaret Murphy, went against the core principle of treating people with “the head, the heart and the hand”.
Moving on
The parents who contacted HIQA, did so to ensure that other parents did not have to go through what they did.
To stop this, HIQA has eight recommendations, ranging from the establishment of an independent patients group and “named accountability”.
While Tony O’Brien accepts the recommendations, he said yesterday that it was “too early” to talk about accountability. He and Dr Susan O’Reilly of the Dublin Midlands Hospital Group pointed to huge steps forward.
These include the filling of key posts, the establishment of hospital groups and more resources being diverted to the hospital.
Shauna Keyes, who lost her son Joshua, said that the report meant her family will no longer be ignored and families will be keen to see if the changes have any effect.
As Murphy put it:
To err is human, to cover up is inexcusable, to refuse to learn is truly unforgivable.
Originally published 7.10am
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What does the EU Membership (France and Germany) think by two superior countries in turmoil?
They have shoved unknown people in top of us by crippling our public services, taken up housing and getting everything handed to them from Social Welfare, Medical Cards, Free Travel etc.
If these two countries don’t stop this nonsense of shoving unknown immigrants into poorer countries like Ireland. The U.K. was right to leave the club of bullies.
@Tommy: lol, we need to be part of something, we’re that small, our economy is that insignificant, the UK have some 65 million people, plenty big enough, we’re beggars Tommy, do you think Germany or France would even notice the blip if we left? :)
@Frank Mc Carthy: What’s with the new ‘Peter Mann’ account? Have you retired one of the others?
@Brendan O’Brien: you’re the troll who’s on here morning noon and night, on every article, harassing people, that’s unstable behaviour
@Peter Mann: How would you know this if you’re brand new to the site?
@Brendan O’Brien: take a break, it will do you good
@Peter Mann: As usual, many of the things you say to others apply to yourself most of all. Surely there must be more to life than 24/7 multi-ID trolling on a website?
@Brendan O’Brien: every article you’re straight in with the juvenile lies & accusations….. obviously, you’re ‘untouchable ‘ by journal.ie moderators but what’s the point?? If this is your only raison d’etre it’s kinda sad & pathetic, no?
@Frank Mc Carthy: You’re not fooling anyone.
@Tommy: There’s a lot of UK worshippers around these days. The inferiority complex is making a comeback.
@Peter Mann: Smells like a Doe, walks like a Doe, talks like a Doe, its a new Doe a/c..
Soon to be banned and respawn as a Paul or Dave G Mann… LOL
@Tommy: It’s not just Ireland getting this influx, it’s every European country, including Uk, Germany and France. It will continue with millions more until either someone/EU says enough or european countries social protection policies crash under the sheer numbers arriving.
@Thesaltyurchin: the would not like it at all because most of the rest of the EU would leave if we left
@Brendan O’Brien: Brendan every now and again I read this rag, but every single time on any given day you’re always posting comments (always in support of the Gov & far left policies) so very obvious that you either work for one of these NGOs, (we do have thirty thousand of them after all) or you work for the Journal…just own it!
@Michael Collins: that doe child is impaired in a way. Getting too much air time as it is with response of any sort. It all feeds his childish sad objective. Best to mute and report it.
@Thesaltyurchin: Maybe it’s a good time to debate the possible benefits or negative impacts of joining BRICS.
@Tommy: wtf are you talking about, economic migrants from Ireland are all over the world
@Tommy: yeah that’s why their economy is busted
@Peter Mann: how you doing frank the wa#k
@Frank Mc Carthy: hi Peter you pri*k
@sean weir: legal….or illegal? No Irish person with a criminal record can set foot in the US or Oz….now are you saying the same goes for here…oh I forgot silly question, when it comes to all the illegals we are welcoming with open arms we have no way of knowing, do we?
@Emer McDonnell: There are 1000′s of Irish illegals in the USA for economic reasons. This has been the case historically.
@Sun Rise: And….are you saying we should condone it?
@James Casey: wha?
Hopefully no charismatic Austrians will be running in this one.
@Don’t Forget: why not?
@Maximilian Kolbe: Really? That’s your comment?
@Louis Jacob: yes
@Maximilian Kolbe: I think he’s referring to the late lamented Chancellor with the ‘tash!
@Maximilian Kolbe: ironic that someone posting under the name of a heroic Saint of the Catholic Church who sacrificed his life to save the life of a man with a young family in a Nazi death camp in the late days of world War 2.
Disgusting that the Journal is allowing anonymous accounts under the names of noble historical characters post toxic slop hateful opinions.
@Maximilian Kolbe: as dim as a one watt bulb
@Brian Hunt: thanks Sherlock
Should have happened in Ireland over Maurice McCabe and the whistleblowers and certainly over cervical check. Ah well, nothing to see Paddy will look forward to years of more things just like it …
@S Suilleabhain: sorry let me correct that immediately for the many history rewriters who gather here. Fg FF would have just survived another no confidence motion(s) they had no business surviving.
Smells like a Doe, walks like a Doe, talks like a Doe, its a new Doe a/c..
Soon to be banned and respawn as a Paul or Dave G Mann… LOL ..
It is high time for Ireland to give serious consideration for leaving the EU, it is an organisation of elites, who like to throw their weight around
@Peter Mann: Luckily Ireland has far too much sense to do that.
@Peter Mann: and your alternative suggestion is ?
An Islamic Republic?
@Thomas Sheridan: I’m afraid, that ship has sailed
@Thomas Sheridan: The commonwealth gives him wet dreams.
@Peter Mann Smells like a Doe, walks like a Doe, talks like a Doe, its a new Doe a/c..
Soon to be banned and respawn as a Paul or Dave G Mann… LOL
@Peter Mann: sure we’d be asked to vote again the right way again if we voted to get out like what happened after the no votes from Nice and Lisbon treaty elections
@Peter Mann: who woke Frank up ??
@James Casey: We got the assurances we required to agree to both treaties. I don’t see any issue.
Germany has lot confidence…
This will displease Putin, so we can expect his standard electoral meddling to commence immediately.
@honey badger: Hey Ursla Honey, your at your usual crap again,, where is your proof of interference from Russia in any country’s election..
@saladin: What kind of proof do you need?
@saladin: Why are you lads always illiterate?
@saladin: well, funny how all these “rumours” are turning up in every election…except in the States where the favourite lost and Outin’s buddy got in
@honey badger: produce the evidence or shut up.
@Louis Jacob: evidence Louis Jacob.. Evidence.
@saladin: The State Senate committee didn’t find any evidence, the Congress didn’t find any evidence, the FBI didn’t find any evidence,, perhaps you have some insider knowledge about these things. Good man
If it’s called for an election, I wonder will the so called ‘far right’ party the AFD win? The same ‘far right’ party that has a lesbian woman as their leader who is pro LGBT. Controlled opposition at its finest.
@Maximilian Kolbe: Controlled by whom?
@Brendan O’Brien: hmm I wonder… I wonder what clique wants to further demoralise the Germans, like the Weimar Republic. ‘What are we going to do with the Germans?’. Hmmm…
@Maximilian Kolbe: I didn’t doubt that it would be some ‘conspiracy’ nonsense.
@Brendan O’Brien: oh really, a conspiracy? Explain why the ‘far right’ party of Germany, selected a Alice Weidel, a woman, who is a lesbian, married to an immigrant from Sri Lanka. Who is pro LGBT. Doesn’t that go against everything the ‘far right’ stand for? Go ahead and give your opinion, I would love to hear it.
@Maximilian Kolbe: Why wouldn’t they prey tell, it’s views they care about so you’re saying a lesbian can’t be a bigot? Can’t hate foreigners? You’re a special type of cluelessness.
@Maximilian Kolbe: far right has been associated with anti women’s rights, anti immigration, anti lgbt and anti semitism. Ok let’s look at the leader of the AFD, and see if their leader represents these far right views… oh wait
@Brian D’Arcy: how could she hate foreigners if she’s married to a Hindu immigrant from Sri Lanka ? That doesn’t even make sense.
@Brian D’Arcy: Ya, I didn’t expect a reply. You can’t come up with a reason.
@Maximilian Kolbe: are you on drugs???
Can I have some ???
@Maximilian Kolbe:
A September 2017 report by Die Zeit claimed that Weidel had illegally hired a Syrian refugee to do housework at her home in Switzerland. The report also alleged that the asylum seeker did not have a written work contract, nor were there invoices for her work. Weidel responded in a tweet that the Die Zeit report was “fake news” and “false” and Weidel’s lawyer stated that Weidel had a Syrian stay at her home as a guest but not as a worker
@sean weir: what does that have to do with her wife being a Hindu immigrant from Sri Lanka?
@Maximilian Kolbe: Have you read their manifesto? 2017 version is available in English, will read through it tonight.
@Maximilian Kolbe: IDIOT,, Your Maxed out man.
The EU is finished
Time for the EU to start listening & working on people’s behalf, the select few like Macron, Scholz, Van Der Lyen & Merkel along with the freaks in the EU Commission who spend their time pandering to the world & woke idealism, have brought Europe to the point of collapse, with the two biggest economies in the EU unable to form Govt’s & France on the precipice of civil war. Unless there is serious correction, control of Immigration & concentration on the bread & butter issues facing people, the EU will collapse from within. Putin must be laughing, he doesn’t need to invade Europe, it will bring it’s own downfall from within.
Another innocuous article about upcoming elections in a foreign country & QUELLE SUPRISE, brenny has it bombarded with over 40% of the comments with his government shilling & racist diatribe. What you’ve reduced this comments section to brenny is simply vile & despicable
@Kevvy kerrr: he is nothing but a nuisance, has every article ruined with childish remarks
@Peter Mann: it’s been said he/ it’s on the payroll?
Moronic Irony from ye Trolls.. esp after weeks of ye guys commentating on US elections and yer love for Trump. And Mr Doe fooling no one with his new Mr Mann a/c… oh and btw LOL.
@Kevvy kerrr: looking like that, nobody else would get away with posting such toxicity
@Michael Collins: It’s just one troll, posting here as Peter Mann, Kevvy kerrr, Frank Mc Carthy and Basildon Joe.
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