ANALYSIS: The quality of health services management at Monaghan Hospital is a key issue, writes Dr Muiris Houston
'The publication of the report by an independent review panel into the events surrounding the premature birth and subsequent death of Bronagh Livingstone is highly significant.
There is substantial variance between this report and the one carried out by the North Eastern Health Board. The Irish Times understands the significant delay in its publication was due to the desire of the independent assessors to produce an accurate and carefully worded document, and not because of any conflict between the Department and the health board.
The independent assessors, led by Dr Séan Daly, Master of the Coombe Women's Hospital, state unequivocally that no attempt should have been made to transfer Ms Denise Livingstone to Cavan General Hospital prior to baby Bronagh's delivery. The assessment team concluded that instead a team of specialists should have been summoned from either Drogheda - where the regions neonatal paediatric unit is located - or from Cavan.
The independent report also criticises the failure to summon the consultant anaesthetist on call at Monaghan that night as well as a failure to mobilise existing resuscitation and specialist neo-natal equipment at the hospital. This equipment is stored in the now disused delivery room in Monaghan hospital, but is apparently in a serviceable condition. It also noted the discontinuation in September 2002 of a system which ensured a midwife/nurse was available for the ambulance transfer of emergency cases.
But it is the independent report's broader conclusions that are most damning. It found a "range of factors" in Monaghan hospital which "may influence the actions of individual practitioners in a way not conducive to optimal care". And in a section that mirrors the concerns of the Medical Council (as reported in yesterday's Irish Times), the independent assessment team refer to "a number of management and/organisational weaknesses", which they spell out.
"We formed the strong opinion that staff are caught in the middle between the North Eastern Health Board, local factions and their loyalty and ties in the community" leading to "a negative effect on staff confidence and morale".
They say no form of facilitation or changed management programme has taken place at Monaghan since the maternity unit closed in March 2001. In other words, they point to a vacuum and a failure by the health board to manage the considerable change of reconfigurating services.
The management structures set up by the health board within the Cavan/Monaghan hospital group are also sharply criticised. Dr Daly and his team say all five members of the senior management team are based in Cavan; and there is no member of Monaghan hospital on the team which administers both.
The assessors' recommendations reflect all these concerns: they suggest a fundamental review of the protocol for the management of obstetric cases at Monaghan General; they recommend the hospital re-initiate a system whereby a nurse midwife is available to accompany obstetric cases during emergency ambulance transfer and they call for the provision of adequate facilities for the delivery and management of premature infants at Monaghan.
Not surprisingly, the team suggest that a "flying obstetric squad" - a group of experts from different medical and nursing disciplines - should be in place to assist in emergency situations such as the Livingstone case. This is standard medical practice in the developed world and its absence within the region up to now has been a significant omission in the provision of maternity care within the NEHB.
By appointing a management consultant to work with the health board in bringing about organisational development at Monaghan hospital, the Minister for Health is signalling clearly where he considers the real nub of the problem lies. By insisting Mr Kevin Bonnar report directly to him as well as the board, he is acknowledging problems which exist in the "internal relationships between key staff". This move, as much as any other conclusion in the report, raises a fundamental question about the quality of management existing within the NEHB.