External Independent Review of Maternity Services at Portiuncula University Hospital Published

The Saolta University Health Care Group has today, May 3rd 2018 published the report of the External Independent Clinical Review of Maternity Services at Portiuncula University Hospital (PUH). This review was commissioned by the Group Chief Clinical Director following a preliminary review which was undertaken by the Saolta Group into the care provided to six women whose babies were referred from PUH for Therapeutic Hypothermia (head cooling)* in 2014.   Based on the preliminary review, protective measures and an intensive monitoring and oversight process was implemented in PUH in December 2014.

An additional 12 cases involving 10 families relating to a number of different perinatal events at PUH dating from 2008 to 2014 were later added to the external review. These cases were identified through a dedicated patient helpline established at that time. A total of 18 cases, involving 16 families from 2008 to 2014 form part of the review published today. This was a complex review process that involved investigators external to the Saolta Group undertaking a full systems analysis of each of the 18 cases. These individual system analyses reports were provided to the families in April 2017 and many families met Professor Walker at that time. Professor Walker and the Clinical Review Team undertook a full clinical review of the maternity service at PUH in addition to reviewing the care provided in each of the 18 cases involved.

In their report published today, the Clinical Review Team state that of the 18 cases reviewed, serious errors in management occurred in ten cases that would have probably made a difference to the outcome for those babies. Of the 18 cases reviewed, six involved cases where the baby had died. In four of these cases there were significant failings in the care provided to those babies. The Clinical Review Team also identified contributory factors and/or incidental findings in each of the 18 cases reviewed.

Commenting Dr Pat Nash, Group Chief Clinical Director Saolta University Health Care Group and the Review Commissioner said, “We are today publishing the report of the external independent clinical review team led by Professor James Walker. We have provided each of the families involved in the review with a copy of this report and earlier today Saolta and PUH management, together with Professor Walker met with the families involved.

On behalf of the Saolta Group, I have again offered the families involved our deepest apologies for the distress and suffering they have endured. We know that this has been a deeply traumatic process for them which has been compounded by the length of time this complex review process took to complete.

*Therapeutic Hypothermia, induced by cooling a baby to around 33 degrees Celsius for three days after birth, is a treatment for hypoxic ischemic encephalopathy (HIE). HIE has many causes and is essentially the reduction in the supply of blood or oxygen to a baby’s brain before, during, or even after birth.

We recognize the profound impact that these events have had on the families involved and we thank them for their willingness to engage with the review process.

I would also like to thank Professor Walker and his team for the complete and comprehensive review process which was undertaken. I would hope that this report and the individual case reports will help give the families the answers that they have been looking for about aspects of their care. My key priority at the start of this process was to ensure that we could learn from the issues that would be identified by the review process, put in place measures to ensure that the highest standard of maternity care is provided at Portiuncula University Hospital, and minimize the risk of this happening again”.

Maurice Power, CEO of the Saolta University Health Care Group added, “I would like to reiterate Dr Nash’s apology on behalf of the Saolta Group. I want to offer reassurance both to the families involved in this review and to other patients and their families that use maternity services at Portiuncula University Hospital that the Saolta Group and Portiuncula University Hospital are fully committed to implementing all the recommendations outlined in this report. Following the completion of the individual system analysis reports, which were provided to each family last year, we established an implementation team to progress each of the 154 recommendations from these individual reports and we will now incorporate the additional recommendations from the overall report.

“We are very grateful that a number of the families involved in this review agreed to be part of this implementation team and are working closely with Saolta and Portiuncula University Hospital staff to ensure that all of the recommendations are implemented as quickly as possible. To date over 90% of the recommendations of the individual systems analyses, most of which are reflected in the report of the external independent review have been completed or are well on the way to being completed. We are continuing to work towards implementing the remaining recommendations.

“I would also like to thank the staff in Portiuncula University Hospital who participated in this review process and who I know are deeply committed to ensuring that they provide a safe and high quality service to their patients. They will continue to work on the full implementation of both the individual system analyses and review recommendations”.

The Review Report

The review report has highlighted a number of key issues relating to the service provided in PUH between 2008 and 2014. These include delays in escalation of concerns to more senior decision makers, deficits in staff numbers across both medical and nursing, poor CTG (trace) interpretation, and concerns relating to the administration of oxytocin during labour. The review report raised concerns around the way many families were communicated with during or after their time in hospital. The report also highlighted historical issues relating the governance structures in place between the hospital and the group at that time.

Since the concerns were identified in late 2014, the Saolta Group and PUH have put in place a significant number of measures to improve patient safety, all of which address the issues raised in the report published today. The review report makes specific recommendations in relation to the need to establish a maternity network within the Saolta Group. This will allow the sharing of expertise and facilitate greater collaboration and teamwork within the network which will strengthen the operational resilience of smaller units such as PUH.

The Group is currently in the process of establishing a Women’s and Children’s Clinical Network across the Group’s hospitals, which will provide for an integrated clinical governance structure for all maternity services in the Saolta Group.

Further to the development of this Clinical Network, we have commenced work to develop a fully integrated maternity service between Portiuncula University Hospital and University Hospital Galway. The maternity services in both hospitals will be managed jointly and future clinical appointments, both medical and other staff will be joint appointments between both sites, with fully integrated training programmes in place. The service will be managed as one single maternity service operating on two different sites with a common system of clinical governance. Policies, protocols and clinical guidelines including quality assurance, incident reporting and incident management will be standardized across both hospitals. This will include a policy for the risk stratification of mothers which will mean that high risk pregnancies are managed on the UHG site or transferred to one of the maternity hospitals in Dublin. This will ensure the ongoing provision of safe, staffed and sustainable maternity services in both hospitals.

The review report also made recommendations in relation to staffing levels. Over the last three years, the number of obstetricians on site has increased from three to five which means that there is a great availability of obstetric consultant support and advice in the unit on an ongoing basis. Five additional Non-Consultant Hospital Doctors (NCHDs) have also been appointed to the maternity unit. There is now dedicated consultant presence on the labour ward during the day, Monday to Friday and the rostered consultant has no other clinical commitments at that time.

An additional Paediatrican has been appointed who is supported by three additional NCHDs, an additional Anaesthetic Consultant with a special interest in obstetric anaesthesia and an additional Anaesthetic Intensivist. These are supported by five additional NCHDs in anaesthesia.

A new Director of Midwifery and Assistant Director of Midwifery for the hospital have been in place since 2017 and they provide senior midwifery leadership on the hospital management team and in the maternity unit. There are now five senior clinical midwife managers who provide 24/7 senior clinical midwife cover on the labour ward. This means that any issues that arise during the course of the care being provided to a woman are now immediately escalated for registrar or consultant input. A Practice Development Midwife is place to support and progress quality improvements, audit and training. A number of staff are currently progressing through advanced clinical courses.

Policies and procedures relating to patient safety have been improved and strengthened. We have developed policies to enhance communication between staff and teams, including the introduction of a twice daily safety pause to identify any emerging issues or concerns and the escalation of high risk cases. We have enhanced and increased our training programmes and provide regular training on neo-natal resuscitation, the management of birth after caesarean section, oxytocion in labour, multi-disciplinary team communications, medical and midwifery handover, obstetric multi-professional training, and fetal monitoring. A programme of multi-disciplinary clinical audit is in place, including weekly C-section and CTG audits. The hospital measures the outcomes of these against clearly defined national standards to ensure that they are providing appropriate care to women.

A specialist bereavement midwife for the unit has been appointed and that person will begin in the next month. This appointment will be the key support person for women and their families who suffer a loss. The hospital is currently implementing the new HSE Incident Management Framework which places a particular emphasis on supporting the needs of service users, families and staff in the aftermath of an incident.

PUH is progressing with a number of refurbishment projects and upgrading facilities in the maternity unit and we have consulted with our service users as part of these projects. The hospital has also replaced and enhanced some equipment such as our ultrasound scanners and our neonatal resuscitares.

There is defined incident management process in place at hospital and group level. A multi-disciplinary team meets weekly in PUH to review any incidents that may have arisen in the maternity unit or the special care baby unit. This team determines what level of action, if any is required and ensure immediate review and escalation to the group-wide incident management time if necessary. Cases are also discussed at the regular group-wide maternity meeting where input and advice is available from senior obstetric and midwifery staff from other Saolta Group hospitals. The Saolta Group has established a dedicated maternity services serious incident management team who will be responsible for the review and management of incidents or concerns that arise in maternity units across the Group. All of these measures are aligned to the National Maternity Strategy.

James Keane, General Manager Portiuncula University Hospital added, “On behalf of the staff at Portiuncula University Hospital I want to again apologise for the failings in care highlighted in this review. We remain committed to providing the highest quality maternity services to our community and the team here in PUH has worked over the last three years to put in place additional measures to ensure we provide the highest standard of care to the women using our services. We are continually monitoring and auditing the service to highlight areas that require improvement or enhancement. We have addressed many of the issues raised in this review report and we are progressing with the implementation of all of the recommendations through the Implementation Group established last year. We will ensure that any recommendations relating to service delivery will be implemented.

Throughout the process we have provided any additional supports necessary, including counseling services to the families involved and we will continue to provide that. We have established a dedicated telephone line 1800 516789 from 10am to 4pm from Friday May 4th and will be open over the weekend, should patients or their families have questions or worries in relation to the publication of this review”.

The report is available here

-The review team membership;

Professor James Walker (Chair): Professor of Obstetrics in the University of Leeds.

Ms Rachel Conaty: Assistant Director of Midwifery and Nursing at the National Maternity Hospital in Holles Street, Dublin from 2008 to 2015.

Professor Sean Daly: Elected Master of the Coombe Hospital in 1998:Mastership 1999-2005: Head of Perinatal Medicine in Coombe Hospital 2005-2010

Professor Eugene Dempsey: Consultant Neonatologist at Cork University Maternity Hospital and Professor of Paediatrics at University College Cork.

Dr Adrienne Foran: Consultant Neonatologist, Rotunda Hospital

Dr Paul Hughes: Obstetrician & Gynaecologist, Kerry

Ms Breda Shiel Kerans: service user representative on the Maternity Services Steering Group

Dr Elaine Madden: Head of Midwifery and Gynaecology at the South Eastern Trust (Belfast).