A damning failure to act in Portlaoise
My Medical Independent column from 23 July 2015 on why the HSE and Department of Health failed to act, given that they knew certain Portlaoise services were dangerous a year before the HIQA report.
An internal, unpublished HSE report, titled the Midland Regional Hospital Portlaoise Performance Diagnostic Report, was obtained by the Medical Independent through a Freedom of Information request. It was cited regularly in the HIQA Portlaoise report, which investigated the safety, quality and standards of services in Portlaoise following the RTÉ Investigations Unit exposure of a series of babies’ deaths there.
The report was written by Ian Carter, the then HSE National Director of Acute Hospitals, and provides a very comprehensive analysis of emergency, medical surgery and critical care services, as well as staffing, finances and management in place in Portlaoise.
It is apparent from reading the ‘Carter diagnostic report’ that its work started before January 2014 because it states that it excluded maternity services once the Department’s Chief Medical Officer began investigating those services in light of the RTÉ programme.
The report’s utterly damning findings are not surprising if one has read the HIQA report first. It found the hospital’s emergency department (ED) was “not clinically sustainable” and that its services should end.
It found Portlaoise had a process of streaming patients into medical and non-medical patients in the ED, which “does not exist in any other 25 EDs and is clearly less than optimal practice”. It also details how many more people are admitted to hospital through the ED at a lower threshold due to an absence of consultants and an over-reliance on agency staff.
It goes on to say that “many internal medical challenges… pose significant risk to patient care and staff wellbeing and require urgent attention”. It states that Portlaoise is “not set up to provide safe, acute and elective surgery”. It found critical care was safe but numbers were too low for it to continue and it should end. It recommended an end to complex surgery and an increase in day surgery.
The report exposes a hospital under significant pressure due to increases in most aspects of care between 2009 and 2013.
Yet it specifies how Portlaoise’s budget was disproportionately cut in 2009, how it never lived within its budget and that this was largely driven by agency staff spending.
The report details a 75 per cent increase in agency spend on nursing, paramedics and medical staff in the hospital between 2012 and 2013.
The report identified three different, unconnected management structures — one was the ‘performance management group’ that had no terms of reference, “blurred focus… very limited consideration of quality and risk”. The second structure was the “senior hospital management committee”, which had no terms of reference and did not meet often enough. This committee was responsible for the hospital’s service plan, yet the report found its service plan for 2013 was not fit for purpose, that it was a “cut-and-paste of national plan” and there was none for 2014. The third group was the “quality and safety committee”, which had potentially 32 members; 19 core and 13 others. There was no clinical audit in place, large numbers of absences from meetings, as well as meetings cancelled or meetings held but with no minutes taken “due to work pressures”.
The report details how there were actually eight “quality-related” committees in the hospital but there was no one actually responsible for quality or risk. They had no review of hospital mortality and the report found quality and safety structures “were not fit for purpose”.
The report is dated 19 May 2014, which proves that senior HSE people knew of unsafe and unsustainable services in Portlaoise Hospital and that certain services, specifically the ED, critical care and complex surgery, should end. The Department of Health confirmed it got a copy of this report in May 2014.
Yet it was not until a year later, after the publication of the HIQA report, that the HSE admits in public that these services will end. While complex surgery is stopping, the ED remains open. Dr Susan O’Reilly, CEO of the Dublin Midlands Hospital Group, is now responsible for Portlaoise and has stated that she is in the process of ending critical care and the ED service, but that this needs to happen in a planned way.
The only reasonable explanation for the previous inaction, I believe, is that it was not politically acceptable to downgrade the hospital. However, in light of the damning HIQA report, they have no choice. Even local TD and Minister for Foreign Affairs and Trade Charlie Flanagan has done a u-turn on his position about wanting to keep all services open in Portlaoise. As recently as September 2014, Flanagan said he’d been reassured that the ED would remain open. However, at a public meeting about Portlaoise in June, Minister Flanagan was heckled when he said he’d prefer to go to St James’s Hospital, Dublin, for complex surgery.
But the question remains unanswered — why did HSE management and the Department of Health fail to act, given that they knew certain Portlaoise services were dangerous and should stop a year before the HIQA report was published?