That report probed the delivery and neonatal care of 18 babies at the Galway hospital between 2008 and 2014. Of those 18 babies, six died and six have medical issues of varying severity.
An external team, headed up by James Walker of the University of Leeds, was commissioned to carry out its investigation in 2015 after concerns had been raised about maternity services at the hospital.
In 2014, six babies had been sent from there to Dublin for therapeutic hypothermia (head cooling) — a treatment often used when a baby’s brain has been deprived of oxygen.
According to Prof Walker, there would normally be two babies a year sent for that treatment from a hospital of the size of Portiuncula.
When the review was launched, a further 12 cases were reported to it through a patient helpline. That meant a total of 18 cases in 16 families were reviewed.
The probe looked at key causal factors (KCFs) — where the baby would have had a better outcome had the care been better.
There were KCFs in eight of the 18 cases. Of those, two babies died after birth and one was stillborn. In another case where KCFs were identified, the baby was diagnosed with grade III Hypoxic-ischemic encephalopathy: A brain injury caused by oxygen deprivation.
KCFs identified included:
- An incorrect decision to defer fetal assessment (it was a holiday weekend);
- Failure to deliver the baby sooner;
- Failure to adhere to guidelines in response to abnormal fetal monitor readings during labour on five occasions;
- Failure to escalate cases to the consultant on four occasions leading to delay in the delivery of the baby and a difficult operative vaginal delivery;
- Failure to recognise the signs and symptoms of a placental abruption at 30 weeks and intervene to deliver the baby sooner.
Prof Walker’s team said a key issue was a lack of support for implementation of change — training was not updated, which could be related to a lack of staff.
It found the skills and training of some frontline staff appeared insufficient and there was an “ineffective” team working in the maternity care provided in some cases.
The understaffing was across midwifery and consultants leading, as the report points out, to “significant locum consultant presence, meaning that there was difficulty in maintaining a safe cover of service when things went wrong”.
The authors also pointed out that for most of the time that they were reviewing, there was no level 3 clinical midwife manager and the two directors of nursing did not have a midwifery qualification.
The clinical review team also said a reconfiguration of the hospitals that formed the Saolta group added to the problems at Portiuncula by creating an unsettled atmosphere there “resulting in a failure to manage change and a blurring of roles and responsibilities which is common in such reconfigurations”.
Their report makes 26 recommendations, a number of which have already been acted upon, particularly around staffing levels.