The CRT report stated that, in 11 cases, there were possible issues related to care. It recommended that “nine cases be subjected to a full systems analysis review”. It also found that, in 19 cases, there was no evidence of a meeting with the patient/family in the case notes provided to the CRT by the HSE.
Among its various recommendations is that all NCHDs working in maternity units “be part of a recognised training scheme”.
The HSE released the report’s Executive Summary, Introduction and Appendix this afternoon. The case notes relate to maternity units in Portlaoise, University Maternity Hospital Limerick and the Midland Regional Hospital Mullingar.
The review of the case notes, which date from the 1980s to 2013, was carried out by Dr Boylan and six other Consultant Obstetricians.
The HSE requested the review in response to concerns raised by maternity patients who contacted Patient Focus or a HSE Helpline after an RTE Prime Time Programme relating to the maternity services at the Midlands Regional Hospital, Portlaoise, which was broadcast in January 2014
Patients who made contact were then written to, requesting consent, if they wished their own healthcare records to be reviewed. When the first 28 patients had consented by midsummer 2014, Dr Boylan’s CRT reviewed the records to determine whether they would recommend a full systems analysis be carried out by the HSE, or whether a meeting with Senior Management or Clinical Staff was recommended.
In a statement today, the Institute of Obstetricians and Gynaecologists, chaired by Dr Boylan, called for the report recommendations to be fully implemented to improve patient safety at maternity hospitals
Dr Boylan expressed his sympathies to the families who have suffered and who consented to having their case notes reviewed.
He added: “The Clinical Review Team has recommended that a representative from the HSE should meet every parent who is affected to discuss its conclusions and recommendations in their individual case. It is clear that the handling of adverse outcomes when they occurred appears to have been a major issue, particularly in smaller maternity units.”
He noted figures recording around five Consultant Obstetricians and Gynaecologists per 100,000 women in Ireland, compared to 27 per 100,000 in other OECD countries. While calling for internationally accepted staffing levels, Dr Boylan said the number of serious maternal incidents in Irish hospitals compared favourably with other European countries, “despite the number of sad cases that have been highlighted over the past year”.
The CRT wanted to see a monthly formal system of audit of pregnancy outcomes involving all relevant doctors. This would allow a pattern of adverse outcomes to be identified in a timely fashion so that appropriate action can be taken.
Other recommendations included the adoption of a formal system of review of adverse outcomes that should be shared with patients in a timely fashion, ideally within two months; and that every effort be made to gain consent for a post-mortem examination, and examination of the placenta, by a perinatal pathologist in the event of a perinatal death.
Each hospital should implement ongoing mandatory training programmes for all clinical staff in respect of day-to-day care of pregnant women, where this does not already exist, it also found.
Meanwhile, the HSE said the recommendations from Dr Boylan’s review will be helpful in informing the development of a National Maternity Strategy.
It added: “Subsequent to the implementation of Dr Boylan’s Clinical Review, the HSE received consent from a further 103 patients for a clinical records review. In view of the volume of cases requiring review, the process was adapted to request that the involved hospital conduct a clinical records review of their own cases.”
