Now is the time to act to ensure safe staffing of our maternity units
Analysis from the Irish Independent 4 June 2016
Over one year since Hiqa published its damning report into five baby deaths in Portlaoise hospital, news emerged of the death of one new-born baby in Cavan hospital, and the death of another baby after an emergency C-section.
Then there was the death of a pregnant woman during emergency surgery in Holles Street during the last 10 days.
Last year, there were 65,977 births in Ireland, and nearly all of these babies were born safely, with mothers and children healthy. But child birth is an extremely risky affair. Death will be an inevitable outcome in a really small minority of cases, but for most death is, or should be, avoidable.
In May 2015, Hiqa found that Portlaoise maternity unit had been unsafe, with insufficient frontline staff, under-resourced to cope with the complex care required. It said the failure to learn from previous hospital inquiries meant more babies’ lives were lost.
That same month, then Health Minister Leo Varadkar and HSE chief Tony O’Brien told the Oireachtas Health Committee that maternity services were safe; new staff, management and governance structures were in place; and people would be held to account.
Irish families giving birth now and in the future need reassurance that everything possible is done to make birth safe and to prevent avoidable risk, and when mistakes are made that they will be treated honestly and promptly. Sadly, this is still not the case.
Cavan hospital maternity services were in the spotlight before, following four baby deaths in the hospital’s maternity unit between 2012 and 2014. The HSE commissioned an independent review of the governance of the maternity services, separate to the reviews of the four deaths.
The review, published in September 2015, is relatively positive. It concluded, “overall, the systems and processes for the assurance of quality, risk, and patient safety are well established and effective at Cavan (maternity services)”.
However, it also identified that “the hospital’s biggest challenge is coping with staff shortages in critical areas, including obstetricians and midwives”. The review found that “smaller hospitals such as Cavan cannot operate in isolation as standalone entities either clinically or financially. They simply cannot sustain the breadth and depth of clinical services… without formal links and networks with bigger, stronger, more specialist units.”
The review praises the facilities and services of a midwife-led unit, yet just 130 out 1,800 births in 2014 were in the midwife-led unit. It identified differences in views between doctors and midwives, with “the doctors very much in charge”, and how this poor multi-disciplinary working exacerbated staff shortages.
At the time of the review, the midwife-to-births ratio was 1:40 and it specified the need to hire “five more midwives to work towards a ratio of 1:37”. It also recommended that “the Assistant Director of Nursing for Midwifery should join the Operational Management Team”.
Cavan hospital is now part of the RCSI hospitals group. The group failed to answer questions put to it by myself this week on whether any of these issues had been progressed since last September. Safely staffing maternity units with the right skill mix is central to ensuring high-quality care. Denying such information to the public exacerbates the loss of public confidence in maternity services.
The internal reviews of just one out of the four Cavan baby deaths pre-2014 is completed. None of them have been published.
When a family loses their healthy mother or child during pregnancy or birth, it is the worst possible thing that could happen. But when the system responsible for their care delays and obfuscates (the reviews may find the deaths were unavoidable) it just makes such a catastrophic experience even worse for them and undermines any remaining confidence in services.
Currently, any adverse incident must be reported to the HSE’s national incident management team and a desktop review is meant to be carried out. If deemed necessary, a more detailed review will take place, usually involving staff and families. Such reviews are ‘internal’ and not normally published.
In some instances, an independent in-depth review will be commissioned by the HSE and in others Hiwa will be requested by the health minister to launch an investigation.
However, despite numerous avoidable maternal and baby deaths in recent years, it is still not clear which cases get examined independently and which do not.
In 2012, a coroner had called for reviews into the deaths of two babies in the Reilly family at Portiuncula hospital. It was only in 2015, after four more baby deaths at Portiuncula were highlighted, that an independent inquiry was commissioned and the Reilly family were given the internal reviews into their babies’ deaths, four years after their second child died.
This Portiuncula baby deaths independent inquiry report was promised by July 2015. It remains unpublished.
Given the erratic and delayed nature of reviews to date, it should be compulsory that all maternal and baby deaths have an independent review, that these must get carried out within a realistic timeframe and the families of the bereaved must be appropriately involved in them.
Similarly with inquests, although hospitals are meant to inform the coroner of all such cases, inquests do not always happen. Making post-mortems and coroners’ inquests into all maternal and baby deaths mandatory would help the truth to be told and enable learning from avoidable deaths.
Now is the time to act to ensure safe staffing of our maternity units and that obligatory, independent transparent processes are in place when things go wrong, so that much-needed confidence in our maternity services can be regained.