Hiqa portlaoise hospital report published

HIQA has acknowledged the “courage and fortitude” of patients and families who took part in an investigation into services at the Midland Regional Hospital, Portlaoise.

The Health Information and Quality Authority(HIQA) was tasked with investigating the hospital after a report by the Chief Medical Officer at the Department of Health was published in 2014. RTE’s Prime Time had also aired a programme about the deaths of newborn babies at the hospital. HIQA's report was published this morning.

In its executive summary, HIQA referred to the 83 patients and their families and said: “It should be acknowledged that their efforts, harnessed with the required actions of those charged with delivering services, should ensure a better experience for those availing of services at Portlaoise Hospital in the future.”

Some patients told HIQA “they were not afforded adequate explanations following an adverse event including the death of a baby or regarding their clinical condition. Some parents said they felt that they were not entitled to an explanation. Others said that unexplained medical jargon left them feeling intimidated and unclear as to what was being said. Parents found that such lack of openness in providing information and explanations compounded their feelings of fear and grief.”

“Parents also described significant delays in the time it took the HSE to respond to their requests for information and explanations following adverse events. The Authority is aware that such delays in the investigation of adverse events have occurred elsewhere in the health services. The current HSE review process is often protracted and leaves families with unanswered questions pending completion of a final report, thereby increasing their upset and trauma,” the report found.

HIQA said evidence gathered during the course of this investigation showed that up until late 2014, patient safety issues were not a standing agenda item for discussion at meetings of the Health Service Directorate, the highest level of management within the HSE.

It also found that “despite the seriousness of the patient safety concerns at the hospital at the time of the Prime Time programme, there was no evidence that key senior HSE managers had visited the hospital in the immediate aftermath of the broadcast to assess the situation in the maternity services.”

The HIQA executive summary noted that: “Although described as a ‘model-3 hospital’ by senior HSE and local hospital staff, the Investigation Team found that the hospital was neither governed, resourced nor equipped to safely deliver this level of clinical services. Furthermore, the HSE itself in 2012 and 2013 had specifically identified clinical risks associated with surgery and emergency medicine, going as far as to say that surgical services at the hospital should cease. However, at the time of publication of this report, the hospital continues to deliver these services.”

HIQA stated that “the findings of this investigation reflect an ongoing failure on the part of the HSE to evaluate the services provided at Portlaoise Hospital against the risks and recommendations identified in previous local and national reviews and investigations conducted by the Authority and the HSE.”

'A national maternity strategy must be developed and published as a matter of urgency. The purpose of this strategy should be to agree and implement standard, consistent, modern-day models of maternity care in order to ensure that all pregnant women have choice and access to the right level of safe care and support on a 24-hour basis. In the interim, inherent risks identified in this report must be urgently addressed and the necessary changes implemented,' the summary noted.

In light of its findings, HIQA has made eight recommendations which it said must be implemented to ensure that risks and deficiencies identified are addressed at both local and national level to ensure the delivery of safe and consistent patient care.