Main findings of the report
• On the maternity ward: The absence of a paediatrician, a neonatal intensive care unit, a community midwifery service, or an elective epidural service were all cited. In 1999, there were 101 Caesarean deliveries, which was 29 per cent of all live deliveries.
"This compares with 13 per cent in the UK and 17.6 per cent for Ireland," the report said.
Because there was only one theatre at the hospital, "emergency Caesarean sections have to interrupt the main theatre or are delayed. As part of the patient record review it was noted that a decision to undertake a Caesarean section on one mother was taken at 16.48 hours, because of foetal distress, and the delivery noted as 17.50. This length of time is unacceptable The decision to delivery interval for emergency Caesarean should be less than 20 minutes."
• On record-keeping: "Of nine obstetric records reviewed, four ultrasound photographs did not have patient identification on them."
No unique identification of patients was found on operating lists. One list of gynaecology surgery had five patients, three of whom had no date of birth or hospital number.
• On facilities: "The physical environment is very poor and has suffered from many years of neglect." The staff office was used as a female changing area for the operating theatre. A consequence "is that staff is seen in their 'blues' about the hospital and canteen without changing".
• On cleanliness: "The area for cleaning dirty instruments is little more than a sink... There is no central sterile supply department's service to the hospital There is no jet washer or ultrasonic washing to ensure adequate removal of organic debris prior to sterilising." At the time of the review, there were also shortages of theatre linen "and these were said to be common".
• On staffing: There was "no clear manpower strategy" and "staff unanimously identified failures in the recruitment process at the health board, and long delays in arranging recruitment
"In addition to the risk identified, the morale in itself is creating risk exposure. There were signs that the staff were dulled to the point of taking unacceptable chances and lowered their standards. They were rationalising poor standards."
• On patient care: "Critically-ill patients were observed by HRRI to be left unattended due to pressures on the staff."
• On medication: Both in the casualty and the female medical ward there were out-of-date medicines and drug trolleys were "left opened and unattended in the wards". In addition, "emergency drugs and equipment are stored on the same 'crash cart' for adults and children. This practice is dangerous."
• On infection control: No surveillance was undertaken. "The hospital has had an outbreak of c.difficile (an infection of the colon) and this was attributed to the poor bedpan washers and lack of facilities, particularly on the female medical ward."
• On management: "There are no clear communication processes within and between management and clinical staff, within and between clinical departments, within and between clinical disciplines and between relevant hospital staff and external stakeholders."