No action on 2006 report for Portlaoise maternity hospital
It has now re-emerged as a key recommendation in the recent Department of Health report examining four infant deaths at Portlaoise Midland Regional Hospital between 2006- 2012. The department report found errors in care leading up to the deaths, including failure to recognise foetal distress. The HSE has confirmed that two more baby deaths at the hospital are under investigation since the report was published.
A report by the Institute of Obstetricians and Gynaecologists, published in 2006, made a number of recommendations strikingly similar to those being made by the Department of Health.
The institute was in favour of the establishment of five clinical maternity networks where smaller maternity units would come under the umbrella of a bigger maternity hospital. The rationale was that it would lead to enhanced clinical governance; provide professional support to clinicians in the networks; improve access to quality care for women and babies; and provide a training framework.
The Future of Maternity and Gynaecology Services in Ireland 2006-2016, put Portlaoise in a group with the Coombe maternity hospital in Dublin. It recommended the network share a common framework for clinical governance and have common protocols, standards, clinical guidelines and pathways of care.
Similar recommendations are key in the department’s report, including that Portlaoise become part of a managed clinical network under a single governance model with the Coombe. In addition, it says there should be common policies, audit meetings, quality assurance, incident reporting and incident management. It also says there should be training for junior doctors and midwives on both sites.
Both reports also reference the need for an agreed national standardised staffing model/national guidelines on rostering of midwifery staff in maternity units.
Former chairman of the institute, retired consultant obstetrician John Bonnar, who made a submission to the institute’s report, said “sometimes there was a price to be paid for not paying attention to reports”.
But he added constrained financial circumstances meant it wasn’t always possible to implement change.
“This happens to a lot of reports, at the end of the day we’re walking a tightrope. It’s a difficult one. It’s not a fire service we should be running, we should be anticipating what the problems will be, but it’s not easy.”
Consultant obstetrician John Higgins, who has responsibility for setting up the new hospital groups, said he was “delighted” to see Portlaoise coming under the control of the Coombe.
At the time of publication, the institute said all maternity and gynaecology units would have to meet the standards outlined in its report by 2016.
