From here to maternity
Recent Medical Independent column from 11 June 2015 on the urgent need for change in maternity services.
For anyone interested in learning how our health system fails people, there is no greater lesson than listening to testimonies at the Oireachtas Health Committee from parents whose babies died in Portlaoise.
Speaking during a three-hour session of the Committee last month, the mother of one of the babies, Róisín Molloy, said: “I have been told that it is normal in such situations for people to go into shock and that, when grieving, people can be stunned into silence. Unfortunately for the HSE, I went in the opposite direction and became the ‘crazy mother’, telling everybody that my child had died when he should not have died and highlighting safety concerns in regard to the maternity unit at Portlaoise hospital.”
There is nothing crazy about her. Róisín’s son Mark died in January 2012 in Portlaoise, having lived for just 22 minutes after his birth. She and her husband Mark believed something very wrong had happened during the birth of their child, even though the hospital and the HSE did their best to deny this to them.
An internal Portlaoise clinical review was carried out just days after Mark’s death, but the Molloys did not know it existed and did not get a copy of it until it was eventually released to them under FOI in April 2014.
There was also a HSE investigation into the causes of baby Mark’s death, a 150-page report with 43 comprehensive recommendations, which was completed in October 2013. Róisín Molloy described how the family had to drive this report to completion.
In short, this report identified a failure by hospital staff to recognise foetal distress, the inappropriate prescribing of oxytocin, and the delayed decision to transfer Róisín to theatre to deliver the baby early. In three out of the other four baby deaths, there were similar failings in care.
Mark Molloy read into the record of the Oireachtas their correspondence and communication with Portlaoise hospital, the HSE regionally and nationally and the Department of Health. This blatantly demonstrated the stonewalling of the Molloys. Their motivations were to find out why their baby died and to make sure it did not happen to anyone else. Due to their sheer tenacity and persistence, a series of baby deaths at Portlaoise were exposed by RTÉ.
Yet, 17 months after the RTÉ programme into Portlaoise hospital, we still do not know how many babies actually died there, what were the causes of each death, who was responsible for the poor care and whether anyone will be held to account.
So why is it that it takes so long for families to find the truth? Amy Delahunt, mother of baby Mary Kate, who died in May 2013, spoke passionately at the Committee about the deliberate delaying tactics. How, when families asked questions, they were told to take the legal route. Yet the moment they took the legal route, any HSE investigation went on hold.
Often, families can get to the end of the legal process where there is a clear verdict of negligence and money paid out, but they still do not know exactly why their baby died. The HSE has now changed this policy so inquiries will go ahead even when legal action is taking place. But despite a joint HSE/State Claims Agency policy of open disclosure, it still has no statutory basis, which means that healthcare providers deny and blame rather than openly disclose when adverse incidents and deaths occur.
Currently, there are a myriad of groups and investigations following the exposé of the Portlaoise baby deaths. There are ongoing inquires into four out of the five baby deaths. Dr Peter Boylan is chairing a group scoping all adverse incidents reported in the aftermath of the Portlaoise programme and currently has 28 cases under scrutiny. Some of these are going back decades and are from other maternity units.
Minister Leo Varadkar has set up a group to oversee the implementation of the eight HIQA recommendations from its Portlaoise investigation and he previously committed to a mechanism to oversee the recommendations of all HIQA reports. In light of Portlaoise, he has reignited the Government commitment to establish an independent patient advocacy organisation and the development of the long-awaited and much-needed maternity strategy by year-end.
But the question remains, will anything really change? The now-withdrawn letter from the Institute of Obstetricians and Gynaecologists, questioning the presence on the maternity strategy group of Róisín Molloy and Shauna Keyes, whose baby Joshua also died at Portlaoise, would seem to indicate that some senior medics are still in ‘bunker mode’.
The public and political attention currently on maternity services means we may well be at a watershed moment, where there is an opportunity to truly reform. However, for this to be harnessed, vested interests must be taken on, significant extra investment must be made and radical change is needed in how our maternity services are organised and provided.