Opening Statement by Dr. James Reilly T.D. Minister for
Health on the Report of the Chief Medical Officer into
HSE Midland Regional Hospital, Portlaoise Perinatal
Deaths (2006-date)
to the
Joint Committee on Health &Children
Leinster House Thursday 6th March, 2014
09.45 am
I thank the Chairman and the members for this opportunity to
speak with them. I will keep my introductory statement as
brief as possible and I will be happy to reply to any comments
and questions that you have.
At the outset I would like to reiterate my thanks to the
families concerned, who, in the face of their individual
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tragedies, had the courage and tenacity to ensure that their
babies’ stories were heard. I can assure those families that we
have listened, we have learned, and we are fully committed to
embedding that learning in all our health services.
It is clear to me that families and patients of Portlaoise
Hospital Maternity Services (PHMS) were not treated with an
acceptable level of care, compassion and respect. I was so
distressed by the experiences of the families I met with that I
immediately requested the Chief Medical Officer to conduct a
review of the safety of PHMS. This review was completed in
three weeks and highlighted some critical issues for the health
service.
The chief Medical Officer’s Report is far reaching. It makes
11 overall and 42 specific recommendations, all of which I
have accepted.
It not only sets out the immediate
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requirements for assuring safety for women attending PHMS
but also provides the strategic direction for maternity services
in Ireland generally.
Clear failures were identified in this preliminary risk and
patient safety assessment of PHMS Maternity Services. This
conclusion is drawn from:
 Portlaoise Hospital’s own assessment of its risk
management processes,
 Current risk management arrangements in place,
 Monitoring of implementation of recommendations from
various investigations of adverse events in Portlaoise
Hospital, and
 Findings made by the Chief Medical Officer in relation
to patient safety and patient care.
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These failures were at both local and national level.
The critical initial question which the Report addresses is
whether the service provided by PHMS can be considered
safe now, and into the future, given the events that were
reported in public and Portlaoise Hospital’s response to these
events.
I understand the significance of these patient safety failures
and I am clear about the next steps that need to be taken. I
have decided on a twin track approach, providing specific
directions and requests to both HIQA and the HSE. In
addition I will be requiring a number of assurances from my
Department.
I want to reiterate a statement here today that I made to the
families and the public last Friday. Portlaoise Hospital
Maternity Service could not be regarded as safe and
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sustainable within its existing governance arrangements, as it
lacked many of the important criteria required to deliver, on a
stand-alone basis, a safe and sustainable maternity service.
On this basis, and with immediate effect, I requested the HSE
last Friday 28th February, to put in place a transition team to
assume control of the maternity service at Portlaoise Hospital.
This team, consisting of appropriate clinical and managerial
expertise, will oversee the planning and execution of an
orderly integration of Portlaoise Hospital maternity services
within a Managed Clinical Network under a singular
governance model with the Coombe Women & Infant
University Hospital. The HSE responded to my request
immediately and a new General Manager and Director of
Midwifery were appointed to Portlaoise the same day. This
interim Management Team will remain in place until a new
governance arrangement is put in place for Portlaoise Hospital
Maternity Service. Dialogue has also commenced with the
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Coombe Women and Infant University Hospital about how
best to provide support to Portlaoise Hospital Maternity
Service in a collobarative working arrangement into the
future.
Furthermore, I have requested the HSE to conduct a review of
Portlaoise Hospital Maternity Service, in respect of services
for the infant and the family following a perinatal death.
The HSE must ensure that effective systems are in place,
including the provision of training where necessary, to ensure
that senior clinicians are competent to take responsibility for
dealing with serious adverse events when they occur,
including dealing appropriately with patients in such
circumstances.
This Chief Medical Officer’s findings cannot be restricted to
the maternity services at Portlaoise Hospital; there are also
ramifications for other services at the hospital and to this end I
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have requested the HSE to address the implications of this
Report for these services.
In addition, I have asked that the HSE also look at other
similar sized maternity services around the country and
consider their incorporation into managed clinical networks
within their relevant hospital group.
The HSE is about to commence a midwifery workload and
workforce review in maternity services in Ireland.
This
project has been jointly commissioned by the HSE Office of
Nursing and Midwifery Services Director and the Joint
Standing Maternity Committee of the Dublin Maternity
Hospitals with the approval of the Director of the HSE’s
Obstetrics and Gynaecology Programme, National Director
Clinical Strategy and Programmes Division, National Director
Quality and Patient Safety and the support of the Chief
Nursing Officer in the Department of Health.
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As I said earlier, the failures identified in this Report were at
both local and national level. I am acutely conscious that there
is enormous pressure on the staff of the Portlaoise Hospital
Maternity Service and of the need to rebuild their morale and
confidence so that they can rise to the challenge of providing
a safe and quality service. Therefore, I have requested the
HSE to provide support to the Portlaoise Hospital senior
management team. This should lead to a wider programme of
support for frontline leaders, particularly in smaller hospitals,
to ensure that they can and do provide safe and effective care.
I want the HSE to ensure that, in the first instance, every
maternity service, and thereafter, every healthcare service
provider, is required to complete a Patient Safety Statement
which is published and updated monthly. This Patient Safety
Statement will include information such as birth rates, adverse
events etc., and should be a requirement of hospital licensing.
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However this is not enough. I consider that a thorough
investigation is required and in accordance with Section 9 (2)
of the Health Act 2007 I have directed HIQA to undertake an
immediate investigation of Portlaoise Hospital Maternity
Services and to report to me by the end of 2014. I anticipate
that many of the, as yet, unanswered questions will be
addressed in the course of the HIQA investigation.
A culture of quality and of safe care is one in which there is
open, kind, transparent, compassionate and sensitive care,
effective team communications and a commitment to
prevention of harm.
A positive patient safety culture is focused on enhancing
every aspect of the experience of a patient. It is well
established in evidence that culture and behaviour are critical
components of safe and effective care. To this end I have
requested that HIQA should also conduct an immediate
assessment of the patient safety culture at Portlaoise Hospital.
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I have also requested HIQA to adopt a standard tool for the
assessment of patient safety culture and team working, and to
use its independent monitoring role to ensure that it is
implemented throughout the healthcare system.
In addition I have asked HIQA to develop national standards
for the conduct of reviews of adverse incidents. In this
context, I have also requested that the HSE should issue a
directive to all providers to require them to notify the director
of quality and patient safety and HIQA of all ‘never events’.
In this case ‘never events’ will include perinatal deaths from
low risk pregnancies. A ‘never event’ by its nature cannot
always be prevented, but the very fact that it happens should
mean an urgent examination by the hospital in question of all
of its systems. My own Department will, through the
forthcoming Health Information Bill, make the notification of
‘never events’ a mandatory requirement.
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An outline of the patient safety risk profile of hospitals in
general and for PHMS specifically was not available in the
preparation of this Report. The requirement to pool
information that may exist across agencies to create better risk
and safety profiling of services is a critical gap in our patient
safety functions nationally. To this end I have recommended
the establishment of a National Patient Safety Surveillance
system by HIQA. HIQA will use this information for risk
stratification and guiding the targeting of their standards
monitoring programme. My Department will examine any
amendments to the Health Act 2007 that may be required.
A broader finding identified in this Report was the systematic
under-reporting of perinatal deaths due to inconsistencies in
Ireland’s perinatal data collection. Specifically this requires a
single definition of a perinatal death for the Irish system. This
will require changes to the Civil Registration Act 2004 and in
this regard, my own Department will work closely with the
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Department of Social Protection to ensure that all official
perinatal mortality rates are calculated using a common
definition.
I have asked my Department to immediately actively pursue
all actions identified for it in this report. I will require regular
patient safety assurance reports from both the HSE and HIQA
to inform me of the progress on the implementation of all
recommendations in this and all other Reports. I will not
tolerate any delays in progressing the critical patient safety
issues that have been identified.
The Report into Perinatal Deaths at Midland Regional
Hospital, Portlaoise is far reaching. It not only sets out the
immediate requirements for assuring safety for women
attending Portlaoise Hospital Maternity services but also
provides strategic direction for maternity services in Ireland
generally.
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This Report will not only inform but will underpin the
planned development of a National Maternity Service
Strategy which will be delivered this year. This strategy will
provide the strategic direction for the optimal development of
our maternity services to ensure that all women have access to
safe, high quality maternity care in a setting most appropriate
to their needs. It is my intention to publish the Strategy this
year.
We need to learn from past mistakes and move on to rebuild
confidence in the safety of our maternity services. The new
Strategy will determine the future model of our maternity
services to ensure that they are fit for purpose and in
accordance with best available national and international
evidence.
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This Report shows that the planned Patient Safety Agency has
a vital place in our health service, which is why it is included
in this year’s HSE Service Plan. The Agency will be
established shortly and applications for a CEO will be invited.
The PSA will be a ‘patients’ champion’, supporting patients to
ensure that they receive an appropriate response to the safety
issues they raise. The PSA will also promote and disseminate
learning on how we can build and enhance a safety culture in
all our healthcare services.
As Minister for Health I am acutely conscious of the
importance of patient safety. The stories of babies Katelyn
Keenan, Joshua Keyes-Cornally, Mark Molloy and Nathan
Molyneaux made a significant impression on me. I want to
once again thank their parents Sharon, Thomas, Natasha,
Shauna, Joey, Roisin and Mark who brought the serious
failures identified in this report to light.
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I listened to the parents when they said they wanted their local
services to be safe and I want to assure them and other parents
that I will do everything within my remit as Minister for
Health to ensure that every step is taken to prevent such
events occurring in the future.
I will now hand over to Dr. Tony Holohan, Chief Medical
Officer of my Department who will give a brief presentation
and overview of the Report he prepared on the Perinatal
Deaths at Midland Regional Hospital, Portlaoise.
I would like to express my thanks to the Chair and the
Committee members for listening to me today.
ENDS.
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