An external independent Clinical Review was commissioned by the Chief Clinical Director of Saolta in January 2015 following a concern that a higher than average number of babies from Portiuncula Hospital in Ballinasloe (PUH) had been referred for Therapeutic Hypothermia following their birth. The review investigated 18 cases and also included a general review of maternity services at PUH between the years 2008-2014.
A report, entitled ‘External Independent Clinical Review of the Maternity Services at Portiuncula Hospital, Ballinasloe (PUH) and of 18 perinatal events which occurred between March 2008 and November 2014’, was published on the 3rd May 2018.
The Clinical Review Team state in the report that the Hospital and the HSE acknowledge that the families’ experiences were, in some cases, devastating, and that these events have had a profound and lasting impact on the families. The incidents described in the report have been highlighted in previous reports in other hospitals in Ireland, to include Portloaise Hospital in 2014 and the report acknowledges that, without fundamental changes in process and training, the problems that arose in Portiuncula Hospital will happen again. The review acknowledges that a shortage in staff numbers, limited access to training and limited availability of resources impacted upon the ability of Portiuncula Hospital to keep up to date with some of the latest developments and skills and techniques in clinical care. The escalation of care to more senior colleagues did not always occur in a timely fashion due to a lack of local escalation guidelines and shortage of consultant staff.
The review highlighted the following clinical key points:
(a) Failure in some cases to recognise an abnormal antenatal and intrapartum CTG.
(b) Failure in some cases to use secondary monitoring such as ultrasound or foetal blood sampling.
(c) Failure in some cases to escalate abnormal intrapartum CTG findings.
(d) Failure in some cases to expedite delivery of the baby.
(e) Prolonged decision to delivery interval in some cases.
(f) Incorrect use of oxytocin infusion in the presence of an abnormal CTG in some cases.
(g) Failure to appropriately escalate care to the Obstetric Consultant in some of the cases reviewed.
(h) In some cases, poor system for contacting the Paediatric staff on call for resuscitation of a sick baby.
It also notes the lack of a detailed investigation of incidents as they occurred, and deals with concerns in relation to communications between midwives and medical staff and also families during labour and after an event.
It makes reference to the fact that there is a need in the hospital to implement open disclosure, and that all staff are to be made aware of and comply with the HSE Open Disclosure Policy. The report notes that of the 18 cases reviewed, 17 of those cases were identified as being cases where open disclosure was deemed unsatisfactory.
In relation to staffing, the review makes reference to a chronic shortage of staff both at midwifery and consultant level, with the lack of consistent midwifery management presence to supervise the labour ward during the period under review. It also comments on the fact that there was no support if things went wrong.
There is significant reference to a lack of training within the review, and it states that the records of the mandatory training shown to the Clinical Review Team, revealed that some staff had little or no record training.
The Clinical Review Team made a number of key recommendations which include the need for maternity services to be appropriately resourced, and that there are improvements in governs structures so as to ensure that staff learn from serious incidents. In addition, it is recommended that there is an improvement in the level of open disclosure occurring with individuals involved in a serious incident, and that there should be development of the appropriate risk assessment to allow autonomous midwifery working with an organised structure of care planning and escalation policies. It goes on to recommend training, to include:
(a) CTG training;
(b) Drills and transfer to theatre;
(c) Foetal blood sampling;
(d) Ultrasound, including doppler and when to use it;
(e) Instrumental delivery and assessment of chances of success:
(f) The appropriate use of oxytocin infusion;
(g) Neonatal resuscitation training programme and local lead;
(h) Identifying babies suitable for head cooling; and
(i) Incident recognition and reporting and incident management and review.
Finally, there is a recommendation that there is a need for a 1:1 ratio of a midwife to each women in labour, and a full review of staffing numbers.
More on the matter in the links below, to include an interview (commencing approximately 22mins into the news) on RTE’s Six One news involving Rachael Liston, solicitor in our medical negligence department, who represents two of the sixteen families referred to in the report.