The HSE failed to take decisive action on defining the role of Portlaoise Hospital and its model of care in the context of the findings of the previous investigations, according to Hiqa’s report into the standards of safety and patient care in Portlaoise, which was released last week.
The report says that the HSE had failed to resource the Hospital sufficiently and to ensure that the governance arrangements in place could safely deliver such a model of care to patients.
For example, up until July 2014 the Emergency Department at the hospital, which was open 24-hours a day, seven days a week, only had a consultant in emergency medicine on site for six hours four days a week.
Parents whose baby had died described significant delays in the time it took the HSE to respond to their requests for information and explanations following those adverse events.
The Health Watchdog, said the current HSE review process is often protracted and leaves families with unanswered questions pending completion of a final report, thereby increasing their upset and trauma.
The report is particularly critical of senior HSE managers.
“Up until the publication of the Chief Medical Officer’s report in February 2014, it appeared that senior HSE managers were predominantly focused on controlling healthcare expenditure.”
Another concern to Hiqa was the face that the State Claims Agency through its Clinical Indemnity Scheme knew of actual or potential risks in the maternity services at Portlaoise Hospital.
Although the State Claims Agency has no statutory powers, it can compel the HSE to implement any recommendations which it may make.
The report claims that Regional HSE management, did not “respond appropriately to the deteriorating situation at the hospital.”
Some senior HSE managers informed the Investigation Team that they were unaware of any safety concerns in relation to Portlaoise Hospital.
The report goes on to say that some senior HSE managers explained that they were not informed of the sentinel cases indentified on the Prime Time programme in a timely fashion, explaining that no alerts or serious incidents had been raised to them nationally.
One senior HSE manager told the Hiqa investigation team that these circumstances were not surprising and will very likely re-occur elsewhere in the system.
The investigation found that there was no evidence of learning following investigations into specific complaints from patients.
The Hiqa investigation team found no evidence that key senior HSE managers had visited the hospital in the immediate aftermath of the Prime Time programme to assess the situation in the maternity services.
In 2012 and 2013, the HSE had specifically identified clinical risks assocatied with surgery and emergency medicine, going as far as to say that surgical services at the hospital should cease. However, the hospital continues to deliver these services.
In conclusion, the Hiqa report said that the findings of the investigation “reflected an ongoing failure on the part of the HSE to evalutate the services at Portlaoise Hospital against the risks and recommendations identified in previous local and national reviews and investigations conducted by the Hiqa and the HSE.”
The report claims that the HSE did not take enough action at a national, regional or local level to adress the issues at the hospital.
Into the future, Hiqa say that the HSE must address the risks and shortfallings of the hospital, as identified in the report in order to imporve the quality, safety and experience of patient care in the hospital.