Portiuncula Hospital Report: Multiple Failures in maternity care

Press Release. Portiuncula Report another blow for confidence in women’s health care in Ireland

AIMS Ireland calls for

  • Mandatory Open Disclosure
  • Figures on mandatory training of HCPs in maternity services
  • Geographical equality for service users
  • Less heel-dragging on Maternity Strategy implementation

Today’s publication of the long-awaited independent report into maternity services in Portiuncula University Hospital serves as yet another damning blow to the women of Ireland’s confidence in their health and maternity services.

In a week of uncertainty and disappointment in our health services, this report serves as another reminder of the HSE’s lack of open disclosure and insensitivity towards grieving families.  The fact that families were not told when things went wrong in Portiuncula, and then had to go digging for answers is unacceptable.  AIMS Ireland again reiterates its call for a mandatory open disclosure policy across the HSE.  Open disclosure is vital for a safe maternity service.

The Walker report highlights a myriad of issues with maternity care in Portiuncula.  Amongst the most concerning being the revelation that babies who could have benefited from treatment readily available in Dublin, were not sent for Therapeutic Hypothermia or “brain cooling”.  This relatively new therapy significantly reduces the number of neonatal deaths and instance of significant disability in suitable candidates.  The report shows that in 2010 one baby was sent from Portiuncula for the treatment, but 2 others born later that same year were not.

“The report highlights that new technologies need to be rolled out rapidly.  This is surely the point of a hub and spoke model of care.  However this did not happen and it appears the care these babies received came down to a postcode lottery” said AIMS chair, Krysia Lynch.

“These cases in 2010 highlight the importance of both ongoing training for all staff and the role of the department of health and the HSE in ensuring a timely roll out of therapeutic treatments to all areas of the country. Where a treatment cannot be made available locally, there is a responsibility on the HSE to ensure that transport systems are in place. It is a sick joke to talk of reconfiguration and the development of hospital networks without investment in the necessary infrastructure to make this possible” she added.

Another major issue highlighted in the report concerns HCP training and the dependency on agency staffing. AIMS has repeatedly requested figures on mandatory training for all staff in maternity units from the office of the HSE’s NWIP (National Women and Infants Programme). This training would include important proficiencies such as CTG monitor reading and interpretation, ECG reading, management of sepsis, neonatal resuscitation.  After over a year of requests we have still to receive any figures. This hardly inspires confidence in the maternity services users we represent that women and babies are being  treated by staff who may not be proficient in the necessary skills.

The report also highlights concerning issues related to establishment of a hospital group, such as a lack of ownership of problems, confusion, alienation of units, staff disempowerment – issues which can be addressed with forward planning.  This is happening across the country as hospital groups are still forming. How can the public have confidence in this process?

“Our maternity services are completely over-reliant on CTG or continuous electronic monitoring.  This is not evidence based care as it is, and now we see, from this and many other maternity care scandals, that these CTG machines are causing more problems than they are solving and being operated and read by staff whom we have no proof are adequately trained to do so” added Ms Lynch.

The report also highlights ongoing problems with hierarchy and patriarchy in our maternity services.  All professionals working together need to have mutual respect for each other while keeping the woman as an equal partner in all decisions.  Ultimately it is her life and that of her baby at stake. There is no place for ego.

“The blueprint for midwifery lead care as laid out in our maternity strategy needs to be implemented without delay.  This model of care, which is the preference amongst service users we at AIMS represent” said the AIMS chair, “It is not just a nice extra available in some cities, it is an essential part of a safe, well functioning service as it frees obstetric care to focus on high risk cases.”

AIMS Ireland again reiterates its condolences to the families involved and again states that the long-drawn out nature of this report is unacceptable. We call for a re-evaluation of the system analysis model of review, currently favoured by the HSE.  The families involved in this enquiry have waited too long for answers.
For further information or to arrange an interview please call Emily McElarney, AIMS Ireland PRO on 0863856225 or email pr@aimsireland.com

Note for editors: AIMS Ireland (Association for Improvements in the Maternity Services) is a voluntary, independent association representing the maternity service user in Ireland.  AIMS has been supporting service users and has represented the service user on working groups for maternity policy for the past 11 years.  AIMS provides a service user representative the Saolta Group.

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