There is no doubt but that many lessons have been learned from the deaths of babies at the maternity unit in Portlaoise hospital.
The steps that have been taken since RTÉ reported on the deaths have turned a unit that was isolated and clearly incapable of delivering into one of the safest and “best staffed” in the country.
In publishing the Systems Analysis Review into the death of baby Joshua Keyes who died in the Midlands Regional Hospital, Portlaoise in October 2009, the HSE in its press statement highlights many of the changes made at the hospital. It also sets out how lessons learned in Portlaoise are helping services nationally.
But what the statement does not do is outline the findings of a report which was published at the request of, and consent of Shauna Keyes and Joseph Cornally, parents of baby Joshua.
The HSE said the report identified a number of “significant failings” into the death of Baby Joshua and the care provided to his mother.
In the wake of the report the HSE and hospital said it “would like to reiterate its unreserved apology to Shauna and Joseph for the failings that resulted in the death of baby Joshua and for the levels of distress caused as a consequence of the prolonged nature of the process which led to the conduct of this review”.
The Systems Analysis Review undertaken in 2014 is an independent review in relation to the care of Shauna Keyes and her baby Joshua at the Midland Regional Hospital Portlaoise. The purpose of this review was to establish the factual circumstances relating to the case and identify key factors that contributed to the care Shauna received prior to and following Joshua’s death. This report is designed to give the family all the information they need in relation to the care they received and also to inform hospital management as to what service improvements are required to reduce the risk of future recurrence. Reviews such as this are not typically published.
The HSE claims that the findings of this report and its 23 recommendations have been implemented in the maternity services in Portlaoise Hospital. Specifically the review highlights key areas of concern related to the interpretation of the Cardiotocography, the absence of foetal blood sampling, the delay in the delivery of Joshua and the care and support provided to Shauna and Joseph following Joshua’s death.
The report, unlike the broad report carried out by Hiqa in 2015, contains many findings and observations that would be lost on the public.
However, little information is contained in the press statement to help inform the public about what went on and why.
It is important to note that staff engaged actively in the review of the case from the time meetings stated in 2014.
The extensive level of engagement and committment to learn and address problems is proof in itself that lessons have been learned. Joshua's death was identified as an incident in 2009 - but the new report found that there was no evidence of a formal review as required.
The Hiqa report on the hospital was the impetus for greater change as it highlighted failings within the HSE.
This report scrutinised Joshua's death but also the minute details of the delivery of care. Some are shocking.
It found that there was no named cosultant obstetrician assigned to cover the labour ward 'during working hours'. The stand-in junior doctor was not on call in the hospital building.
The HSE say the key measures taken to address the concerns include:
- Appointment of additional staff and increased staffing levels in the maternity unit in accordance with the Birth Rate Plus Study, including shift leaders on all duties.
- Foetal blood sampling in place with continuous training
-Mandatory CTG monitoring training
- A number of new guidelines are in place including, the use of oxytocin, foetal heart monitoring and foetal blood sampling
-Provision of an oncall room in the labour ward for Obstetrician registrar onsite 24/7.
- Lucas classification of urgency of caesarean section has been adopted into use and an individualised approach to assessment of urgency is in place.
- The introduction of a guideline to support mothers and families experiencing neonatal death and the introduction of a bereavement committee and midwife with a special interest and training in bereavement support.
The HSE says tha other improvements have been made at maternity unit include;
- New management and governance arrangements;
- The development of quality safety and risk management structures.
The HSE says the report will also drive improved services maternity units throughout Ireland.
Key developments in this regard already include:
dissemination of a number of key clinical guidelines relating to obstetric services including sepsis management; management of a critically ill woman; pregnant or postpartum; clinical handover; and management of miscarriage
implementation in all hospitals of the National Early Warning Score (NEWS) and the Maternity Early Warning System (IMEWS) in the 19 maternity units
development of standards on bereavement services for families affected by adverse outcomes
development of mandatory CTG trace training
establishment of Women and Infants programme and advertisement of key posts
approval to appoint directors of midwifery to all 19 units to strengthen clinical governance and senior decision making reporting by the 19 maternity units on 30 quality assurance indicators since August 2014
development of maternity safety statements on a monthly basis with effect from October 2015
A National Implementation Group has also been established by the HSE to drive the action plan agreed arising from the Chief Medical Officer, HIQA and HSE reviews relating to Portlaoise. The Plan sets out clear milestones, timelines and accountable persons for delivering on the actions. These combined actions are intended to strengthen the delivery and oversight of Irish maternity services.
The proposed establishment of managed clinical maternity networks over the coming months will further augment the clinical governance and leadership within maternity units with the objective of delivering high quality patient centred services to women and babies.
Many families have been affected by adverse outcomes in our maternity services over the past number of years. The HSE deeply regrets the distress and anguish caused to these families for its failure to respond in a timely and empathetic way to these issues. It is Shauna and Joseph’s expressed wish that the publication of Baby Joshua’s report will assist in ensuring that recommendations will be implemented nationally, and most importantly to prevent unnecessary suffering, injury and loss of life.