Severe clinical incidents in maternity services match international norms – State Claims Agency

A further breakdown of the figures reveals that there were four maternal deaths and 38 deaths of infants last year.

According to the State Claims Agency, while 75 clinical incidents were rated as extreme in severity, not all of these were avoidable.

The Agency stated that some related to unavoidable natural events, significant congenital abnormalities, or miscategorisation regarding severity factor, and that the overall national incident rates in the Irish maternity service are not dissimilar to international figures where comparisons were available.

However, Head of Clinical Risk with the Agency, Ms Dubhfeasa Slattery, acknowledged at the launch of the report that the figures were an under-representation of the total number of severe clinical incidents due to the variation in patient safety incident reporting and the lack of standardisation that exists nationwide.

It is hoped that better quality and consistent data will result from maternity services becoming more familiar with the National Incident Management System (NIMS), which was launched in 2014.

The majority (96 per cent) of acute hospitals nationally in the first quarter of 2015 reported to NIMS, although the Agency says that all hospitals are now compliant.

The majority of acute hospitals responded that they report between 75 and 100 per cent of incidents to the SCA, while nine hospitals (18 per cent) stated they reported only 50 per cent or less of the incidents to the Agency.

The six most common maternity claims were categorised as: Perineal tear; shoulder dystocia; stillbirth; unexpected neonatal death; cerebral irritability/neonatal seizure; and ‘other’.

The total expenditure on clinical claims in maternity services was 54 per cent of all clinical care- related claims in 2014.

The total expenditure on maternity-related claims has increased by 80 per cent from €32 million in 2010 to €58 million in 2014.

Also, total expenditure on cerebral palsy claims increased 77 per cent from €27 million to €47 million between 2010 and 2014.

The Director of the SCA Mr Ciaran Breen said that this increase is primarily due to lump sums replacing certain previous Periodic Payment Orders.

Mr Breen also said the SCA was often unfairly blamed for the delay in payment for some families and that the introduction of pre-action protocols would significantly reduce the time families wait for payment.

The <em>Clinical Incident and Claims Report in Maternity and Gynaecology Services: A 5-Year Review, 2010 and 201</em>4, also found that delayed and cancelled surgery increased 10-fold in the period under review.