HIQA REPORT: To err is human, but to cover up is unforgivable

The HSE has been accused of ignoring “more than a decade” of serious patient safety concerns flagged by staff, patients, and official reports, culminating in the deaths of eight newborn babies in “extremely traumatising” circumstances.

The Health Information and Quality Authority issued the damning critique after publishing a 208-page report into the deaths at Portlaoise Hospital.

Speaking at the launch of the report, the officials criticised the HSE for repeatedly failing to act on clearly flagged fears. Inquiry member and patient advocate Margaret Murphy warned: “To err is human, but to cover up is unforgivable and to refuse to learn is inexcusable.”

Team member Martin Turner said Hiqa is “unable to definitively conclude services at the hospital are safe” for women giving birth today — with similar problems “very likely to occur elsewhere”.

The Hiqa investigation was launched after an RTÉ expose in January 2014 uncovered the deaths of five newborns from a lack of oxygen between 2006 and 2012 after staff failed to properly monitor signs of foetal distress. Three more baby deaths were uncovered after Hiqa was contacted by 83 families.

The Hiqa report found that:

  • HSE management at local, regional, and national level failed to act on concerns raised about maternity service standards by the State Claims Agency “as far back as” 2007, which could have “substantially reduced” risks to patients;
  • Recommendations from eight previous reports about staff and patient levels at other facilities between 2009 and 2013 were not fully implemented at Portlaoise Hospital, despite impacting on the facility’s services;
  • While a maternity assessment unit was set up in late 2007, the necessary increase in midwife numbers was not addressed for a further eight years after “media and political attention”;
  • The HSE was “in possession of information that indicated its own clinical care programmes had expressed concerns about the quality and safety of acute and general medical services, paediatrics, and surgery”, but did not address the problems;
  • “General nurses and midwives felt safety was not treated sufficiently seriously by the hospital”, with budgets given greater priority.

The report states that a new national maternity service plan needs to be developed, and that all hospitals should undertake a “self-assessment” to ensure they have implemented all previous recommendations relating to them.

“It is regrettable and unacceptable that a number of the issues identified by this investigation have previously been examined in detail,” the report states.

“These recurring findings indicate a basic and worrying deficit in the Irish health services: Namely the capacity and capability to reflect on the findings of all reports, reviews, and investigations, and apply system-wide learning from these findings.”

In cases described in the report as “grossly inappropriate and extremely traumatising”, parents of deceased babies were given remains in “a metal box” with the baby “squeezed in to fit”. The parents were “reprimanded for crying” and felt they were “troublemakers” for raising care concerns.

Hiqa chief executive Phelim Quinn said reforms must be acted on immediately and that budget constraints are “no excuse”. Noting that previous recommendations relating to Portlaoise Hospital and other facilities have not always been acted on, he said Hiqa wants an independent patient advocacy group to be set up by May 2016 as the HSE cannot be trusted to implement the measures.

HSE director general Tony O’Brien apologised for the deaths and said he held his hands up to the fact the system “has been challenged in translating lessons from one location to another”. However, he refused to say if anyone will be held responsible, claiming the HSE response “has been effective, swift, and decisive”.

Health Minister Leo Varadkar said anyone reading the report can see “more than a decade of missed opportunities to put things right”. He added that “for various reasons, many legitimate, I don’t think the public trusts the HSE”.

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