A report into the deaths of four babies at the Midlands Regional Hospital in Portlaoise says the maternity service can't be regarded as safe and sustainable within its current governance arrangements.
The damning report, published this afternoon, says there were clear failures in the management of risk and patient safety in the Co Laois facility.
The Health Service Executive has put in place a transition team to take control of maternity services in Portlaoise, as a result of the findings.
The Health Minister James Reilly (pictured below) embracing Natasha Molyneaux who's baby Nathan died in Portlaoise:
Our News Correspondent Fergal O'Brien reports:
Family members of the babies who died in Portlaois (pictured below) became emotional as the details of the report were read out:
Mark Molloy (pictured below with his wife Roisin) who's son Mark died in Portlaoise in January 2012, says today is a bittersweet day for his family:
Report Conclusions:
1. Families and patients were treated in a poor and, at times, appalling manner with limited respect, kindness, courtesy and consideration.
2. Information that should have been given to families was withheld for no justifiable reason.
3. Poor outcomes that could likely have been prevented were identified and known by the hospital but not adequately and satisfactorily acted upon.
4. The PHMS service cannot be regarded as safe and sustainable within its current governance arrangements as it lacks many of the important criteria required to deliver, on a stand-alone basis, a safe and sustainable maternity service.
5. Many organisations, including PHMS, had partial information regarding the safety of PHMS that could have led to earlier intervention had it been brought together.
6. The external support and oversight from HSE should have been stronger and more proactive, given the issues identified in 2007.
Report Recommendations:
Recommendation O.R.1: PHMS should apologise unreservedly to the patients concerned.
Recommendation O.R.2: An immediate assessment of the patient safety culture at Portlaoise Hospital should be undertaken by HIQA.
Recommendation O.R.3: A team should be appointed to run the PHMS pending implementation of Recommendation O.R.4 below.
Recommendation O.R.4: PHMS should become part of a Managed Clinical Network under a singular governance model with the Coombe Women & Infant University Hospital.
Recommendation O.R.5: Other small maternity services should be incorporated into managed clinical networks within the relevant hospital group.
Recommendation O.R.6: The HSE should address the implications of this Report for other services at Portlaoise Hospital.
Recommendation O.R.7: Support should be provided to the Portlaoise Hospital senior management team. This should lead to a wider programme of support for frontline leaders, particularly in smaller hospitals, to ensure that they can and do provide safe and effective care.
Recommendation O.R.8: HIQA should be requested to undertake an investigation in accordance with Section 9 (2) of the Health Act 2007.
Recommendation O.R.9: HIQA should develop national standards for the conduct of reviews of adverse incidents.
Recommendation O.R.10: The HSE should ensure that every maternity service (and later every health service provider) be required to complete a Patient Safety Statement which is published and updated monthly.
Recommendation O.R.11: A National Patient Safety Surveillance system should be established by HIQA.
