In a statement on 30th January 2018,, the National Maternity Hospital objected to a HIQA review under section 9.2 of the Health Act, following the untimely death of Malak Thawley. The NMH have said that a review of this nature is “without justification, undermines clinical and public confidence and could be counter-productive in its effect on national maternity services”, and “This conveys to our staff and our patients that the Minister believes that emergency surgical practice in this Hospital outside ‘core hours’ is unsafe.”
Malak Thawley died in May 2016 following a catastrophic cascade of failures in care during an ectopic pregnancy. Similar failures in care also led to the death of Nora Hyland in Feb 2012, which also returned a verdict of medical misadventure, following a 37 minute delay for blood products during her Caesarean birth. One of the key issues in the Malak Thawley case was the lack of on site Consultant Obstetric cover. Instead the hospital operated (and still does operate) a 24/7 “on call” consultant obstetric cover. This means that on weekends and on bank holidays or in the middle of the night there might not be a Consultant Obstetrician on site, but on call and emergency situations will be overseen by a registrar until the Consultant Obstetrician comes in.
Maternity care can be a fast changing area of medicine, in which every potential live saving factor needs to be permanently in place. This includes blood products, expertise and surgical equipment.
The National Maternity Hospital, is a a tertiary referral centre with as many as 8,000 plus births a year. The patients who use their service need an absolute assurance from an independent source that the service is safe. On this occasion the Master’s word is not enough.
Lets not forget that the hospital does not exist to serve itself and its own culture and staff, the hospital exists to serve the women and babies of Dublin and in many cases far beyond.
An independent HIQA review may well find that the need for immediate state investment, which would be in the hospital’s interest, and of course in the interest of those who use it.
AIMS Ireland are disappointed with the National Maternity Hospital’ s intransigence towards a HIQA review. Objections to a HIQA review echo past failures in transparency and a lack of accountability which have plagued the Irish maternity services for decades. The women and families using the Irish maternity services deserve the confidence in knowing that failures in care have been fully examined from every possible angle including systematically and that those responsible will be held accountable. When women die in our maternity services we need to be assured that every last ounce of learning can be obtained from a tragic situation. We need to know how and why the death happened, we need the learning to be transferable to other units and ultimately we need an assurance that if the same situation were to occur the outcome may well be different.
Speaking earlier today, AIMS Ireland Chair, Krysia Lynch said, “Public perception and staff morale whilst important to those working within an institution, should never be used as a means to limit transparency, accountability and transferable learning. This is about ensuring patient confidence, patient safety and public assurance. Women want to walk through the doors of their maternity unit without concerns and doubts”
Lynch continued “Women deserve to know they will receive the best possible care with skilled, highly trained professionals looking after them, who can cope with any eventuality in the maternity continuum They also need to be assured that when mistakes happen, they will be fully evaluated and compared to a national independent standard and that any learning can be transferred to other units.”
Lynch concluded “A HIQA review will give us more information and lead to improved services and so it should happen. If the NMH are practising within HIQA standards for Safer Better Maternity care then they will have nothing to worry about and staff morale will be boosted by that message of compliance and excellence entering the public domain”.
Wednesday 7th February 2018
AIMS Ireland calls for an external review into the Malak Thawley tragedy in the NMH