Midland Regional Hospital staff’s behaviour ‘well short’ of reasonable standard
Speaking at a press conference in Dublin yesterday, Dr Holohan said he was recommending that the Health Information and Quality Authority quickly review the culture of the entire hospital.
He said the treatment of the babies who died, and of the families, fell well short of an appropriate standard that would be exhibited in any other maternity service. “It is something that gives us a lot of concern,” said Dr Holohan, who did not think this could be explained by staffing levels.
“It is really difficult to understand why issues around access to babies after the event of death for the purposes of holding, dressing or washing was a difficulty in the case of the individual deaths that we heard about.”
He said the response to families after the adverse incidents took place fell well short of what he thought would be an appropriate response.
Patients found themselves on their own instead of having the support of the hospital. In some cases patients found themselves having to deal with risk managers.
“When serious adverse events occur that’s the time we expect our senior clinical leaders to do their best work; to step forward and to take responsibility in that situation. It did not happen in many of these cases.”
He said evidence was found of other serious adverse events and they knew of at least one other investigation of another perinatal death following the death of baby Mark Molloy in 2012.
Dr Holohan said the clinical investigations that the department was able to identify fell well short of an appropriate standard. “The reports, where they took place, took too long to complete; they started too late and the standard to which they were completed was highly variable.”
Dr Holohan said HIQA would be drawing up national standards for such investigations. “We need to be clear that when things go wrong the systems to learn those lessons and apply them as quickly as possible are in place and working effectively. That did not happen in this case.”
Health Minister Dr James Reilly said it was clear to him that the families and patients at the hospital were not treated with an acceptable level of care, or compassion or respect.
He said he found the report distressing to read as a doctor.
Clearly emotional, Dr Reilly told the families who attended the conference that he admired their tenacity and commitment to ensure that their babies’ stories were heard.
“I want to assure you that I have heard your stories and I have listened and they will make a significant difference in how we manage our maternity services into the future and I don’t say those words lightly.”
Dr Reilly said Portlaoise Hospital maternity service could not be regarded as safe and sustainable within its current governance arrangements.
He said it lacked many of the important criteria required to deliver on a standalone basis a safe and sustainable maternity service.
The minister has asked the HSE to look at other similar-sized services and consider their incorporation into managed clinical networks within their relevant hospital group.
Dr Reilly said he was recommending the establishment of a national patient safety surveillance system by HIQA. To put it more plainly, he said, it would be like a fire alarm.
“Currently, we don’t have that. We depend on good people like the parents in this room or the hospitals themselves to put their hands up, but that clearly is not sustainable or satisfactory.”
