HSE calls for audit of pregnancy outcomes

Every hospital in the State should have a formal system for auditing pregnancy outcomes, a HSE-established review recommends.

Such an audit, conducted monthly, would allow a pattern of adverse outcomes to be identified quickly and acted on, the report states.

It also recommends that the results of adverse outcome reviews should be shared with parents within two months of the incident occurring.

A total of 28 cases were reviewed. Issues to be addressed were identified in 10 cases and, in six of these cases, the baby was either stillborn or died in the neonatal period.

The review was in response to concerns raised by patients after RTÉ showed a programme about baby deaths at Portlaoise Hospital in January 2014.

The cases reviewed dated from 1985 to 2013 — 23 related to Portlaoise, three to University Hospital Limerick, and two to the Midland Regional Hospital in Mullingar.

The review was conducted by Dr Peter Boylan, chairman of the Institute of Obstetricians and Gynaecologists and his clinical review team of six obstetricians.

None of the patients’ reports are published in the review. Only individual patients have received their own report.

After Dr Boylan’s review was implemented, the HSE received consent from a further 103 patients for a clinical records review; 94 related to Portlaoise Hospital.

Due to the volume of cases, it had been decided the hospitals conduct a clinical review of their own cases, led by senior staff.

It is expected that patients in the larger group will receive the report of their clinical review by the end of next month.

The review process will be similar to that followed by Dr Boylan’s clinical review team when they examined the first 28 cases.

A breakdown of the 28 cases shows that 14 involved pregnancies where the baby was either stillborn or died shortly after being born. Seventeen mothers were expecting their first baby.

Of the cases examined, one related to a retained swab, one related to a wound abscess, and another to a massive obstetric haemorrhage.

One was of an infant death at 10 months; two related to babies who were micro-cephalic; and there was one case of cerebral palsy in a child who is quadriplegic.

There were three cases where multiple questions were raised and one case was of an undetermined neurological problem.

The report makes 10 recommendations, including that hospitals should:

• Make every effort to gain consent for a postmortem in the event of a perinatal death;
• Ensure there are midwives trained in ultrasonography who are available during the working week and on-call at other times;
• Have trained bereavement counsellors to deal with perinatal deaths;
• Ensure that both midwifery and consultant obstetrician staffing levels are at an adequate and internationally accepted level;
• Have ongoing mandatory training programmes for all clinical staff for day-to-day care of pregnant women.

The HSE said the recommendations would be helpful in informing the development of a national maternity strategy, which was recently launched by Health Minister Leo Varadkar.