It is crucial how we manage the process of change in our medical services,writes Dr Muiris Houston, Medical Correspondent
Recruitment advertisements for the North Eastern Health Board proudly proclaim that the board is "Putting People First".
In the light of the tragic events in Co Monaghan in the early hours of Tuesday, it is reasonable to question whether services provided by the health board gave Denise and Brona Livingstone any opportunity to be "put first" and offered a minimum standard of medical care.
Speaking on RTÉ radio yesterday, the baby's grieving grandfather said his daughter, Denise Livingstone - she was 24 weeks pregnant - woke with labour pains and was brought by her partner to the accident and emergency department of Monaghan General Hospital.
Despite the fact that the hospital is supposed to offer a 24-hour casualty service, the doors were closed.
When the couple went to the front door of the hospital, it was answered by a porter, who informed them that it no longer provided maternity services, and advised them to continue to Cavan Hospital.
According to Mr Livingstone, Denise's womb was contracting every three minutes or less, and her partner insisted on her being seen. Following an assessment by a doctor and nurse, an ambulance was called and the expectant mother and her sister began the journey to Cavan. We were told that no medical staff accompanied them. Predictably, Denise gave birth while en route. Brona breathed and cried but died later that morning in Cavan Hospital.
Just over 12 months ago, maternity services were withdrawn from Monaghan General Hospital by the North Eastern Health Board. All deliveries would now take place in Cavan, a 25-minute journey from Monaghan Town but a considerably longer journey from the north of the county. Because of bad road conditions, the journey takes 50 minutes from hospital to hospital.
Having taken the decision to transfer maternity care as part of a longer term plan to rationalise services in the north-east, what has the health board done to smooth the transition for mothers who hitherto delivered in Monaghan?
Regrettably, an analysis of the Livingstone family experience suggests very little contingency planning took place.
There has been no extension of the maternity unit at Cavan Hospital. Extra beds have been crammed into existing facilities. And, crucially, no adequate plan or protocol was initiated to deal with the possibility of premature delivery by mothers from the north Monaghan area. Although up to 20 midwives remain at Monaghan Hospital, they are currently employed in general nursing duties. No plans have been made to organise a roster of nurses to ensure their availability to assess cases such as Denise Livingstone prior to transfer. Nor are there arrangements to ensure that a trained midwife could travel in an ambulance to Cavan in such critical situations.
THE North Eastern Health Board has not provided a dedicated maternity ambulance to the people of Monaghan following its decision to transfer services to Cavan. It has not made arrangements to allow maternity cases to be assessed in the emergency unit of Monaghan Hospital. On one occasion in the last year, when a humanitarian decision was made by nurses and obstetric staff to deliver a woman in labour at the hospital, the staff were allegedly rapped on the knuckles and told that the health board did not have insurance cover to allow such a practice.
Nor does the board appear to have considered setting up a "flying obstetric squad" based in Cavan Hospital to respond to emergencies within Co Monaghan. This is a well-accepted practice in developed countries, in which an obstetrician, paediatrician and a midwife are dispatched to stabilise both mother and new-born prior to bringing them to hospital in a specially-equipped ambulance.
Any inquiry into this tragic case must ask the following questions of the health board:
Was a protocol put in place to offer a safe alternative to expectant mothers following the withdrawal of maternity services in Monaghan?
Did the management of the hospital delegate clinical decision-making to a night porter as part of its new arrangements?
Were an anaesthetist and a midwife available at the hospital on Tuesday morning, and were they called to see Ms Livingstone?
Why, as alleged by the Livingstone family, were the doors of the casualty unit closed even though the hospital was on call for medical and surgical emergencies?
Is the board satisfied that it is making the best available use of fully-trained midwives who remain working at Monaghan General Hospital despite the absence of an obstetrics and gynaecology service?
Are fully-trained, emergency medical technicians (EMTs) available on all ambulances serving the Monaghan area?
The initial reaction of the Minister for Health has been to hide behind the recommendations made by professional bodies such as the Royal College of Obstetricians and Comhairle na n-Oispidéal. However, he must be reminded of pre-election promises he made while on a visit to Monaghan earlier this year. He assured hospital staff and others that full gynaecological and surgical services would be retained there. By next month, neither acute surgical or gynaecology services will be available at the hospital.
While it will be impossible to retain a full range of services at every acute hospital in the Republic in the years ahead, the process of change as services are moved elsewhere is a crucial one.
Speaking at a Competition Authority conference in Dublin last month, Prof Muiris Fitzgerald, professor of medicine at UCD, said in reference to smaller hospitals in the State: "Some of these hospitals aspire to deliver a 24-hour service and that is not sustainable. They should be reconfigured and right profiled."
It is the adequate reconfiguration of maternity services which has failed in the north-east. With further changes to local health provision imminent, the people of Monaghan must be concerned at what lies ahead. Unfortunately, what is Monaghan today will be Mallow, Roscommon, Navan and Nenagh tomorrow. All of these small hospitals are due to be "reconfigured" as the process of change sweeps through the health service.
The Minister for Health must make difficult decisions if the Monaghan tragedy is not to be replicated in the months and years ahead.