Maternity care saga has not been resolved by HSE review

Analysis: Despite apologies for failings, the health executive has yet to take action

After initial reluctance within the HSE, over 200 complaints were referred to a review team chaired by Dr Peter Boylan. Photograph: Dara Mac Dónaill

After initial reluctance within the HSE, over 200 complaints were referred to a review team chaired by Dr Peter Boylan. Photograph: Dara Mac Dónaill

 

The HSE Maternity Clinical Complaints Review is the sixth report sparked by the tragedy of a series of unnecessary baby deaths in Portlaoise hospital, which came to light three years ago.

By casting its net wider, and further back, than any of the preceding reports, it attempts to draw a line under one of the sorriest recent chapters in Irish healthcare.

The cases under examination here date back as far as 1975, and relate to births not just in Portlaoise, but nine other maternity units. However, Portlaoise is still the unit most under investigation, just as it has been since the RTÉ documentary on the hospital in 2014 led to a flood of complaints from other women who suffered problem births.

After initial reluctance within the HSE, over 200 complaints were referred to a review team chaired by Dr Peter Boylan, and 153 woman consented to have their cases reviewed.

Chaotic review

The process of review has been protracted and even chaotic, as Patient Focus has pointed out. Even Dr Susan O’Reilly, head of the local hospital group, admitted the process got off to a wobbly start two years ago with a failure to include patients and their advocates in the first phase of review.

It is heartening that lessons were learned along the way.

In the first phase, 28 patients received just a copy of their case notes along with a slim report. In the second phase, an enhanced screening process was developed involving meetings with outside experts and individual patients from the outset.

This still didn’t amount to the gold standard of HSE investigations, known as a full systems analysis. The HSE argues this would have taken years, given the requirement to find expert opinions and to give staff right of reply.

In the event, publication of the review has taken some years. It is evident, though, that with the passage of time, there is a greater willingness by the HSE and senior doctors and midwives to engage with patients in a more transparent way.

Poor care

Patients were still not given a written review of their cases, and many were worn-down by the length of the process. Yet, the second phase did result in further apologies being issued. In some cases, this related to bad communication or lost files, but in other cases, there was poor care and babies died.

This prompted a look back at 90 deaths at Portlaoise over a 30-year period, but no evidence was found of a similar failure to correctly interpret CTG traces being a contributory factor in these outcomes.

There comes a point when it is time to stop delving into the past and the future must be prioritised.

Yet, there must also be accountability for past events. Once again, there is no sign this will happen in relation to Portlaoise. No staff will be disciplined on foot of this latest report.

A separate, long overdue report on what sanctions, if any, could be imposed on managers arising from the controversy is still not complete. The complaints procedures of the HSE remain labyrinthine and baffling.

Until these deficits are remedied, the line cannot truly be drawn under this sorry saga.