The Health Service Executive (HSE) has apologised to 14 families over the handling of their births, including eight in which a baby died, as recommended in a newly published review.
In four of these cases, hitherto unknown, grossly abnormal CTG (cardiotocographs) tracing – monitoring the baby’s heart beat during labour – was discovered, the Maternity Clinical Complaints Review has found.
However, a historical review of cases between 1985 and 2014 at Portlaoise hospital found no evidence of a trend of failing to respond to abnormal CTGs that might have been a contributory factor in the deaths of babies.
The review, chaired by former National Maternity Hospital master Dr Peter Boylan, looked at 153 maternity-related complaints made in the wake of an RTÉ programme on baby deaths at Portlaoise, broadcast in January 2014. The cases spanned 40 years and most related to Portlaoise.
The incidents found during the review were previously unknown and unreported, and came to light “accidentally”, according to Patient Focus, which participated in the review.
Of the cases where apologies are to be issued, nine were for care that was not consistent with best clinical practice, and three of these involved a perinatal death.
One case related to cerebral palsy, three to poor communications and two to lost or delayed healthcare records.
The review team did not identify any trends in clinical practice among current staff at Portlaoise “which would require referral to disciplinary processes”.
Among the report’s 12 recommendations are calls for mandatory training for staff in CTG interpretation, immediate communication with families who suffer a bereavement and timely open disclosure to patients when adverse events occur.
Concern over timeliness
Patient Focus expressed concern that the HSE was unable to conduct a “timely” review that met the needs of patients and families and, as a result, it was very difficult for them to feel included and confident that their concerns mattered.
“The process was ad hoc. There was much chopping and changing evidence in method and overall approach.
“The process stumbled along until eventually a productive approach was adopted. It should not have happened in this way.”
The group says women who made complaints should have been offered access to a written medical review of their case. “This was suggested over and over again but did not happen. The HSE cannot continue to reinvent the wheel when major incident reviews are needed.”
Patient Focus has been dealing with the families of babies who died at Portlaoise hospital since 2012, when it was approached by Mark and Róisín Molloy, whose baby Mark died in the maternity unit that year. Following the RTÉ documentary in January 2014, which highlighted concerns over four baby deaths at the unit, the HSE set up a helpline to receive concerns from women and their families.
In 2014, a national review process was set up to deal with the scores of concerns received. In a first phase, 28 cases were reviewed by a panel of obstetricians.
Patient Focus said this phase was a major disappointment as written testimonies by women were excluded.
However, it praised the second phase, in which affected women were offered meetings with obstetricians and midwifery experts with the support of patient advocates.
A third phase of the review consisted of a historical lookback over cases but this did not find any significant incidents.
Regret
Minister for Health Simon Harris expressed regret that it had taken such a long time for the issues involved “to have full visibility”.
“The number of these complaints over such a long period of time is a wake-up call to all of us to ensure our health system becomes more open, and deploys systems that are responsive, and listen and learn from patients.”
Dr Susan O’Reilly, chief executive of the Dublin Midlands Hospital Group, apologised for the time taken to complete the review and said patients felt they had not been listened to in the past.
Dr O’Reilly said real improvement had been made and the maternity unit was safe.
