ORGANS WERE retained by the Rotunda Hospital for unacceptably protracted periods and without the knowledge of parents according to a report into post-mortem practices at the hospital between 2000 and 2007.
The report found that in both periods "it is likely that families are unaware that these organs have been retained”.
The report by a review group chaired by Ian Carter found of 189 cases, 24 organs were retained even though permission was only given for postmortem.
Some 129 cases of organ retention were “non-compliant” with the conditions of consent from parents.
In 92 cases, organs were retained for more than one year without parental consultation about burial or disposal and parents were unlikely to be aware of this retention, the report said.
In seven cases, families expressed dissatisfaction that postmortems had not been completed 13 months after delivery, or of organs not released for two years, because the processing of organ sampling had not been completed.
In terms of accountability no one person appeared responsible for the “totality of the autopsy process”.
A consultant pathologist identified as “consultant A” was “freed-up” from all clinical work, to address issues in an earlier national audit but after concern was expressed by independent auditors his work was stopped altogether, according to the report.
It found consultant A conducted 429 postmortems of which 133 resulted in organ retention, while another pathologist, identified as consultant B conducted 223 and in 12 cases organs were retained.
Consultant A completed 38 reports retrospectively for organ retention, including 16 in 2005 and 13 in 2006.
In many cases there was a “significant delay” in the processing of samples.
Only 12 per cent of A’s post-mortem reports were completed within the six-week target timeframe, set down in national guidelines. The report also noted two cases where A completed reports retrospectively for postmortems conducted by B.
Consultant A told the inquiry “that retrospective completion of records was undertaken at the request of hospital management”.
In a statement consultant A said that he was required to work for prolonged periods on his own because of restrictions on consultant resources.
The review group made 31 recommendations including that “parents have a right and a need to know that the hospital retained organs” and that the parents should be informed.
Master of the Rotunda Hospital Dr Sam Coulter-Smith said the hospital was writing to as many parents as they had contact details for in the affected 138 cases and would place newspaper advertisements to contact the remainder of parents who were unaware of the retention.
He apologised on behalf of the hospital and acknowledged “the very difficult and stressful situation in which these families have been placed”.
He acknowledged the serious concerns raised about “professional performance” of staff and said it required careful examination.
An inquiry into the Rotunda was conducted following a national audit of organ retention conducted by Michaela Willis. Problems were identified at the Rotunda Hospital and a separated investigation was ordered and carried out by the Carter group.
The review group found practice at the Rotunda at variance with other maternity units “both in terms of overall organ retention” and in retention of organs for education and research.
The group “would suggest this significant delay” in “blocking tissue” or processing of samples “is unacceptable and has resulted inappropriately in non-consented organ retention” for more than one year in 92 cases and “significant delays for families wanting to secure reburial”.
Retrospective consent for autopsy was found in 10 cases, and in eight cases the wishes of parents were not complied with in regard to organ retention. Retention records were introduced in 2000.
If parents cannot be contacted the organs should be disposed of within a three-month period. There should be a specific policy for informed separate consent for postmortems, for the retention of blood and other bodily fluids, retention of images and materians for genetic investigation.
The hospital has opened an inquiry line 1800 303 265 for parents whose babies underwent a postmorten before May 1st, 2000.
The “Look Back” report into the Rotunda Hospital made 31 recommendations including:
Parents should be informed about organs retained without their consent.
Parents should be given a choice for disposal of organs.
If it is not possible to contact parents organs should be disposed of within three months.
Specific and separate informed consent should be given for postmortems; retention of blood and other body fluids; retention of images; retention of organs and retention of material for genetic investigations.
The HSE should consider the development of a countrywide consent policy in relation to autopsy to achieve a national standard.
Parents should not have to formally record they do not consent to an autopsy.
Parents should be given a full copy of the consent record.
A postmortem group should be responsible for the oversight of the overall autopsy process, practice and corrective actions where performance targets are not achieved. Significant non-compliance instances should be considered routinely by the risk management function.
The hospital may want to consider “parent” representation on this group.
Helplines: phone services in place
Special helplines have been set up by the HSE and Dublin’s Rotunda Hospital to deal with issues raised in the audit of retained organs at hospitals across the State and the separate investigation into postmortem practices and organ retention at the Rotunda.
The HSE’s dedicated phone line can be reached at freephone 1800 670 700. It will be open today and tomorrow from 10am to 6.30pm. It will also operate next week, Monday to Friday, from 10am to 6.30pm.
The Rotunda’s helpline number is 1800 303 265. It will be open today from 10am to 11pm, tomorrow from 10am to 6.30pm, and from Monday to Friday next week from 10am to 6.30 pm.
