HSE clashed with department over Portiuncula problem births

Senior management at the Department of Health and the HSE differed sharply on the seriousness of problem births identified at Portiuncula Hospital, documents reveal.

The department and the HSE also clashed on their approach to the problems at the hospital in Ballinasloe, Co Galway, where significant shortcomings have been identified in the management of at least seven deliveries. The department expressed anger at being left in the dark and said agreed procedures for escalating serious issues had not been followed, the documents obtained by The Irish Times show.

The problems at Portiuncula emerged in the form of an “unusual trend” identified last October, after four newborns were transferred to Dublin for head-cooling treatment. Three more babies were sent the following month for the treatment, which is used to lessen the chance of brain damage resulting from oxygen deprivation during birth. Two of the cases under review resulted in death.

Correspondence with the department shows the HSE successfully resisted apologising to the families of the babies involved and claimed it was not clear that harm had been done.

In contrast, Dr Tony Holohan, chief medical officer at the department, insisted "it cannot be said that harm did not occur". "What is in question," he told the HSE, "is whether poor outcomes will result when assessed in future follow-up."

Each of the babies were born at full term and were normally formed, he pointed out, but experienced a “poor outcome” consistent with intra-partum hypoxia (lack of oxygen)”.

Arguments between the Department and the HSE last month over the seriousness of the issue and the wording of public communications contributed to a delay in informing the seven women of the review and in setting it up, the documents show.

Whistleblower

The cases became public only after a whistleblower contacted media last month, forcing Saolta University Health Care Group, which includes Portiuncula, to issue a statement at the behest of the HSE. Although more than four months had elapsed since the first problems were identified, staff had still to make contact with all of the families involved.

Hospital staff and Saolta appear to have responded promptly to the emerging trend late last year. A review was ordered and senior HSE management in Dublin were notified in late November.

In early December a preliminary review raised “serious concerns” about practices in the maternity unit and a number of measures were put in place to address risk. In spite of this, an audit carried out two weeks later found four cases of significant concern out of 22 deliveries examined.

Saolta and the HSE, which have insisted there is no ongoing risk at the hospital since measures were put in place to address the seven cases, have never referred publicly to this audit.

Although HSE management in Dublin was informed of the problems on November 29th last, they were never mentioned when officials went to meet Minister for Health Leo Varadkar about maternity services on December 22nd.

The background is important here. The death of Savita Halappanavar in University Hospital Galway in 2012 prompted a slew of reports and recommendations for improving maternity care.

These included better training and quicker escalation of problems by bringing them to the attention of more senior people.

Then, last year, a cluster of problem births emerged at Midland Regional Hospital in Portlaoise, many of them involving the same issues that were emerging at Portiuncula.

Letter

Despite this, the Minister was left in the dark for a month, as was his Department, until Dr Holohan was copied on a letter from HSE director of acute hospitals Dr Tony O’Connell to HSE director general Tony O’Brien on December 29th.

The Department was appalled at learning about the problems so late. "This is particularly surprising in light of the meeting on Monday, December 22nd, with the Minister on maternity services in Portlaoise Hospital, the discussions between the Department and the HSE on maternity services in Portlaoise during the week beginning December 15th and the various ongoing discussions on maternity services between the Department and the HSE over the past year," wrote assistant secretary Tracey Conroy to Dr O'Connell.

But Dr O’Connell too was in the dark until late December about what was going on in one of his hospitals, though in the meeting with the Minister he raised issues about sustainable staffing levels and an over-dependence on agency staff at Portiuncula.

The HSE gave the Department assurances about the safety of services in Ballinasloe and said there were “no previous concerns” in relation to this.

Failings

This is hard to square with the finding of a 2011 review which identified serious failings in the management of Lorraine Reilly’s labour in Portiuncula a year earlier.

Ms Reilly’s daughter Amber died aged one week in circumstances similar to the seven cases since identified.

Ms Reilly and her husband Warren have lobbied successfully to have Amber’s case included in the independent review which is due to start soon.

Throughout January, department and HSE officials argued over whether to acknowledge that the seven babies had been harmed, and whether to apologise to their families.

Dr O’Connell told the department a draft statement from the hospital group was “too strong” because it unconditionally apologised and stated that harm had occurred. “We believe the preliminary report is inadequate because the neonatal charts haven’t been analysed. At this stage we believe the approach has to be that alarm bells are ringing but nothing is definite.”

With no sign the health service was going to publicly disclose what was going on, the whistleblower forced the pace by leaking information to the media. Reference to apologising to the families was removed from the ensuing press statement hours before it was released on January 22nd.

The review has since been extended to cover at least 12 cases and a UK-based chairman has been appointed.

However, the rest of the inquiry team has yet to be appointed because of a difficulty in getting Irish-based specialists to serve on it.