Cavan deaths: More babies die while lessons still not learned

Early last Sunday morning, while the rest of the world slept, an ambulance rushed a young woman from her home in the northeast to Cavan General Hospital.

The pregnant woman was experiencing massive bleeding and urgently required medical attention. She was admitted to the hospital where doctors worked to stop the haemorrhaging and determined she needed an emergency Caesarean section.

In small maternity units there is no 24-hour obstetric service and consultants provide cover on an on-call basis. This means they stay within five minutes of the hospital so they can get there quickly.

The on-call consultant can tell staff over the phone to get ready for an emergency section by transferring the patient to the operating theatre and “prepping” her while the consultant drives in.

Doctor out of contact

The system works fine most of the time but breaks down if the on-call consultant cannot be contacted. A consultant needs to give the go-ahead for the procedure and to be present when it is carried out.

If the on-call consultant cannot be contacted, efforts are then made to contact other consultant staff. The potential for delay is obvious given these staff won’t be ready for work and the fact that time has already elapsed.

There are different versions about what happened in Cavan at the weekend. According to one version, there were difficulties contacting the on-call consultant on the phone. An off-call colleague was then contacted but by the time he arrived and carried out the emergency section, it was too late and the baby had died.

Other sources say the immediate priority of doctors was to stabilise the woman’s condition. There was no delay in summoning obstetric intervention, it is said.

An investigation will help determine what exactly happened, but it may not prove possible to establish this with certainty.

The second death that occurred in Cavan followed a normal delivery. The baby was born healthy but got into difficulty at the age of about 15 hours and died. The cause of death was not clear at the time but a postmortem may shed more light on this.

The deaths of two babies in the same maternity unit in the space of a week is unsettling, but is not of itself evidence of poor care or organisational failings.

Despite the huge progress made in modern medicine, obstetrics included, some adverse events occur unexpectedly, and/or beyond the control of doctors. For most mothers, giving birth will be an uneventful, safe experience, but in a tiny minority of cases things can go badly awry.

In such cases, it is vital to establish whether these adverse events were preventable and what lessons can be learned for future medical practice. But has this happened in Cavan?

The maternity unit has known its fair share of controversy in recent years, including four investigations into previous baby deaths and a number of high-profile court cases. The latest incidents will prompt the same questions about the safety that have been raised over recent years.

It is of concern that we know so little about the outcome of the previous cases. None of the four reports has been published so far. One of the investigations had to be redone after a legal challenge from the consultant involved.

An inquest into a baby death in 2012 heard allegations from a consultant obstetrician that he delayed an emergency Caesarean section due to the unavailability of nursing staff for the operating theatre.

Maintaining staff

When previous controversies erupted, former minister for health

James Reilly

seemed to promise an independent investigation. However, this never happened as the Health Information and Quality Authority said it was never asked to conduct one.

Instead, the HSE brought in an English management consultant to run the rule over Cavan. He wrote up a short report highlighting staffing and morale issues but his brief did not extend to a proper examination of clinical standards.

Cavan’s corrected perinatal mortality figures are below the national average; in 2011, 2012 and 2013 there were 1.5, 3.1 and 3.1 deaths per 1,000 births, compared to a national average of 4.1.

There are four consultant obstetricians in Cavan but one has been on administrative leave for more than 18 months. A locum is filling the position.

Cavan is not alone among smaller hospitals in struggling to recruit and maintain qualified staff.

The recurrent controversies in the maternity unit won’t help, and neither will the slow pace of investigation into deaths.