I thank the Chairman. On behalf of the Health Information and Quality Authority, HIQA, I thank the Joint Committee on Health and Children for giving me the opportunity to discuss our investigation into the safety, quality and standards of services provided by the Health Service Executive, HSE, to patients in the Midland Regional Hospital, Portlaoise. As the Chairman noted, I am joined by Ms Mary Dunnion, director of regulation and by Mr. Marty Whelan, our head of communications and stakeholder engagement. We welcome this opportunity to appear again before the joint committee and to engage with members.
Following a request in 2014 from the former Minister for Health, Deputy James Reilly, in accordance with section 9(2) of the Health Act 2007, HIQA has investigated the safety, quality and standards of services provided by the HSE to patients in Midland Regional Hospital, Portlaoise. This is the seventh statutory investigation carried about by HIQA since 2007.
On 30 January 2014, an RTE investigations unit "Prime Time" programme was broadcast about the tragic deaths of newborn babies in Portlaoise hospital and the subsequent management of patients and their families by the hospital and the HSE. Following the broadcast, the then Minister of Health asked the chief medical officer of the Department of Health to conduct a preliminary assessment of perinatal deaths and related matters from 2006 up to that point in 2014 in the maternity services at Portlaoise hospital. Following publication of the chief medical officer’s report, the board of HIQA considered and agreed to a request from the then Minister for Health to conduct an independent investigation into the services provided by the HSE at Portlaoise hospital.
This statutory HIQA investigation has been carried out in line with the authority’s published terms of reference and published guidance in order to make recommendations to improve the safety, quality and standards of services provided by the HSE. Central to this investigation was the experience of a number of patients and families whose experience of care fell well below the standard expected in a modern acute hospital. The assessment of these patients and families’ experience reflects their experience of care and its aftermath when they raised concerns at local, regional and national levels of the HSE. I would like to acknowledge the courage and fortitude of the many patients and families who made contact with the authority to outline their experience of care within Portlaoise hospital. It should be acknowledged that their efforts, harnessed with the required actions of those charged with delivering services, should ensure a better experience for those availing of services at Portlaoise hospital in the future.
This investigation examined the quality and safety of maternity and general clinical services at the hospital, and the Health Service Executive governance arrangements in place nationally, regionally and locally.
In his report, the chief medical officer said two HSE reviews into breast cancer misdiagnosis cases at Portlaoise hospital, published in 2008, should have provided a very strong case for external oversight and support to Portlaoise hospital as it dealt with those issues. HIQA strongly reiterates this view. Throughout this investigation it has found examples of weak oversight and variable levels of action by the HSE at national, regional and local level in relation to risks to patients at Portlaoise hospital. Two previous HIQA reports relevant to Portlaoise hospital were the investigation reports into Ennis and Mallow hospitals, published in 2009 and 2011. Both reports stress that patients with complex needs should be directed to hospitals with the necessary staffing, competence, infrastructure and equipment for safe and effective care. Our latest investigation found that the HSE – as the provider of health care services – failed to take decisive action on defining the role of Portlaoise hospital, its model of care and the nature and profile of services that could be safely delivered on the site in the context of the findings of previous investigations.
As the committee is aware, this investigation was initiated as a result of very negative experiences of a small but significant number of patients and their families at Portlaoise hospital. When the investigation started, HIQA was contacted by or received information on 83 patients and their families, most of whom had used the maternity services at Portlaoise hospital. While the purpose of the investigation was not to undertake a detailed examination of individual patients’ care, in line with the investigation work of other regulatory bodies internationally, hearing the experiences of service users is an invaluable part of this process. The experiences of these individuals and families helped to inform the investigation and gave a range of personal perspectives on the quality of care received and helped in shaping the findings and recommendations in the report.
Parents who spoke with the investigation team gave examples of poor communication with hospital staff where they were not afforded adequate explanations following an adverse event including the death of a baby or regarding a clinical condition. Some parents said they felt they were not entitled to an explanation. Others said that medical jargon left them feeling intimidated and unclear about what was being said. Parents found that such a lack of openness in providing information and explanations compounded their feelings of fear and grief. Parents also described significant delays in the time it took the HSE at all levels to respond to their requests for information and explanations following the adverse events. HIQA is aware that delays in investigation of adverse events have occurred elsewhere in the health services. 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. As a result of these delays safety issues may potentially remain unidentified and unresolved for lengthy periods of time.
There were many reasons the HSE should have maintained very close oversight of the quality and safety of services at Portlaoise hospital. These reasons included local and national HSE inquiries and clinical reviews into patient-safety incidents, significant service failures, statutory investigations of hospital services, and resultant publication of findings and recommendations. However, there was no evidence that the HSE nationally was proactively exercising meaningful oversight of the hospital and the inherent risks identified there.
Another concern of the investigation team was that for seven years prior to the chief medical officer’s report, the State Claims Agency through its clinical indemnity scheme knew of actual or potential risks in the maternity services at Portlaoise hospital. HIQA recognises that the State Claims Agency does not have statutory powers by which it can compel healthcare institutions, including the HSE, to engage with it or to implement any recommendations which it may make. However, we are concerned that the interaction between the State Claims Agency and the HSE on the sharing and use of available information did not result in effective mitigation of the identified risks.
The investigation team found that Portlaoise hospital continues to provide undifferentiated, namely, in all manner of conditions, emergency services 24 hours a day seven days per week. It also provides undifferentiated surgical services where there is a low number of complex surgical cases going through the hospital. The investigation team found that Portlaoise hospital had major deficiencies in corporate and clinical governance arrangements. Although described as a model-3 hospital by senior HSE and local hospital staff, the investigation team found that the hospital was not governed, resourced or equipped to safely deliver this level of clinical services. In 2012 and 2013 HSE itself specifically identified clinical risks associated with surgery, emergency medicine and acute medicine and said that surgical services at the hospital should cease.
Following interaction with HIQA about concerns for the governance at Portlaoise hospital, in 2013 the then HSE regional management altered the local management arrangements. The purpose of the alterations was to increase the interaction between regional and local management structures and bring decision-making powers onto the hospital site. However, despite overwhelming evidence to suggest that the local management team at Portlaoise hospital was struggling to deliver the service, there is no evidence to show that the regional HSE managers took effective control of the situation at that time. The senior hospital management committee was responsible for providing safe, effective services through leading and directing performance of the hospital. The minutes of these meetings show little evidence that the committee was effective in identifying or implementing actions to address quality and safety issues within the hospital.
HIQA also concluded there were significant ongoing problems with workforce planning in Portlaoise hospital. The absence of a clear vision for the hospital, coupled with the national imperative to reduce the staff headcount, ensured that planning was focused on counting staff rather than on the type of services the hospital should be delivering and the competencies needed to deliver them.
Risk management structures in the hospital were poorly developed. Incident management at Portlaoise hospital was largely reactive and focused on recording incidents. It was evident that the deficiencies in risk management processes in the hospital contributed to the poor experiences described by patients who met the investigation team. As part of the investigation, HIQA assessed the prevailing patient safety culture in Portlaoise hospital using the safety culture index. The results, used to inform our lines of inquiry of this investigation, suggested that Portlaoise hospital did not have a strong patient safety culture.
Increasing pressure on maternity services at Portlaoise hospital was highlighted as far back as 2004. Deficiencies in midwifery staffing had been identified in a review carried out by the hospital in 2006. These issues were not substantially addressed until 2014, following publication of the chief medical officer’s report. At the time of writing this report, an interim management team including a general manager, risk manager and director of midwifery had been put in place and were effecting positive change. However, a senior obstetric lead had not been appointed to the maternity department to provide independent senior experienced, obstetric, clinical leadership - despite a direct request by HIQA to the director general of the HSE in September 2014 to do so following our concerns about the absence of adequate clinical leadership in the maternity unit and failure to progress a clinical network with the Coombe Women & Infants University Hospital in Dublin.
Since the chief medical officer’s report, midwifery staffing levels have significantly improved with the appointment of senior clinical midwifery managers, shift leaders, a bereavement specialist, a clinical skills co-ordinator and a clinical midwife specialist. One additional consultant obstetrician has also been appointed.
Clinical experts on HIQA's investigation team identified a lack of senior clinical leadership and supporting formal clinical network arrangements – and current staffing arrangements for non-consultant hospital doctors – as a serious concern and risk for the sustainability of the maternity services at Portlaoise hospital.
These experts considered it vital that a system of rotation be designed between Portlaoise hospital and a large maternity hospital such as the Coombe Women & Infants University Hospital. Setting up a clinical network incorporating Portlaoise hospital and the Coombe Women & Infants University Hospital is an essential first step in developing such a system of rotation.
Poor standards of multidisciplinary communication were highlighted by a number of people who met the authority. These concerns were reported as far back as 2007 and had not been addressed. Additionally, concerns over the governance arrangements for ultrasound scanning services and effective clinical audit at Portlaoise hospital were identified during our investigation. Specific issues relating to service capacity, staff competency and clinical oversight of the ultrasound service were acknowledged by the hospital management team.
Portlaoise hospital provides a 24-7 emergency service for adult and paediatric patients with any degree of seriousness or complexity of illness or injury who present at the hospital. The clinical governance arrangements in the hospital’s emergency department were unsatisfactory and over-complicated. Despite the fact that both the HSE’s emergency medicine programme and acute medicines programme had previously identified concerns over these arrangements, the inherent risks remained unaddressed.
The HSE’s own emergency medicine programme considered that the emergency department was not appropriately resourced to provide a 24-7 model of emergency care. Also, the HSE’s unpublished performance review in 2014 concluded that a 24-7 emergency care service at Portlaoise hospital was not clinically sustainable. At the time of this investigation, the clinical profile of emergency department patients is still not being actively assessed to inform the type of service that is required to best meet the needs of those patients presenting to it.
The overall volume of critical care activity within the intensive care unit of the hospital was low. The intensive care unit does not meet the minimum requirements for critical care, patient confidentiality and privacy, and it was not fit for purpose. Senior clinical staff were aware of the limitations of the care that could be safely provided there. They confirmed that if necessary, patients are transferred to a more appropriately resourced hospital.
A report by the HSE in 2014 recommended that critical care services in the hospital should be discontinued. In light of this HSE review and the concerns of senior local clinicians, the investigation team is not assured that critical care services are sustainable in Portlaoise hospital. The surgical services at Portlaoise hospital operate a 24-7 emergency service basis, catering for all degrees of surgical illness or injury arriving at the hospital. Most hospital inpatients using the surgical services at Portlaoise hospital were admitted through the emergency department.
Two recent HSE reviews of the surgical services at Portlaoise hospital both concluded that the hospital on its own was not structured to provide safe, acute and preplanned surgical care. The investigation team found that low numbers of complex surgical procedures were being carried out at the hospital. As previously reported by the authority, surgeons who do not have the opportunity to treat sufficient numbers of patients or carry out a sufficient volume of procedures run the risk of becoming de-skilled. This potential risk has not been addressed at Portlaoise hospital.
The investigation team found that medical services at Portlaoise hospital required significant restructuring and resourcing in order to deliver a service aligned to the HSE’s acute medicine programme. Despite the recommendations of the HSE’s acute medicine programme, the hospital did not have a medical assessment unit or a bed management structure. This investigation also found that the medical team was under-resourced, with local clinicians reporting that two extra medical consultants were needed for care of the elderly and endocrinology. These appointments would also help release the hospital’s clinical director from general medical duties for 25 hours each week in order to increase time for the functions of the clinical director role.
The diagnostic imaging service at Portlaoise hospital is significantly under-resourced with a lack of resources preventing the development of strong clinical governance arrangements to ensure the quality and safety of service delivery. At the time of reporting, the diagnostic imaging service is overly reliant on one clinician. Therefore, this model of care is clearly not sustainable.
The findings of this investigation reflect an ongoing failure on the part of the HSE to evaluate the services provided at Portlaoise hospital against the volume of patients attending the hospital and the profile of their clinical needs, and the findings of aligned risks and recommendations identified in previous local and national reviews and investigations conducted by this authority and the HSE. The findings of this HIQA investigation highlight again issues and recommendations that have been identified on a number of occasions previously in both internal HSE reviews and independent HIQA investigations.
This investigation concludes that Portlaoise hospital was allowed to struggle on despite a number of substantial governance and management issues over the quality and safety of services. Sufficient action was not taken by the HSE at a national, regional or local level to address these issues.
The experiences outlined by patients and families during the course of this investigation were disturbing when viewed within the context of the delivery of a modern health service. These experiences highlight significant deficiencies in the delivery of person-centred care at Portlaoise hospital. Poor experiences by patients and families were compounded by ineffective governance arrangements at all levels of the HSE with the result that the patient’s voice was ignored, and valuable insights and learning were lost.
The HSE must now address the risks and deficiencies identified within this report in order to improve the quality, safety and experience of patient care in Portlaoise hospital. It must also ensure that where similar risks and deficiencies exist in other hospitals, these are addressed as a matter of urgency. The HSE governance arrangements to support the implementation of the national recommendations contained in this investigation must be clear, with a named accountable person or persons with overall delegated responsibility for implementation. The implementation plans should include clear timelines and identified individuals with responsibility for each recommendation and each associated action.
A national maternity strategy must be developed and published as a matter of urgency. We welcome the establishment of a steering group to advise on the development of such a national maternity strategy. The authority acknowledges the work that has been done to date to incorporate the maternity services at Portlaoise hospital into a clinical network with the Coombe Women & Infants University Hospital and welcomes the recent signing of a memorandum of understanding between the Coombe Women & Infants University Hospital and the Dublin-Midlands hospitals group of the Health Service Executive.
In light of the findings of this investigation, the authority has made eight recommendations which must be implemented to ensure that risks and deficiencies identified are addressed at both local and national level to ensure the delivery of safe and consistent patient care. Among the recommendations in our report is the creation of an independent patient advocacy service to ensure that patients’ reported experiences are recorded, listened to and learned from, and reports published. Lessons learned should be shared between hospitals within the new hospital groups, between hospital groups and nationally throughout the wider health system. I hope to address some of our recommendations in more detail in reply to questions from committee members. It is imperative that these recommendations are fully implemented and that a clear timeline is set out and followed up, with named individuals taking responsibility for the implementation of each recommendation.
Given the significant system-wide recommendations in the report, it will be vital that there is the necessary political commitment to their managed implementation in order to drive further improvements in the quality, safety and governance in our health services. The authority therefore recommends that the Minister for Health should establish, as a priority, an oversight committee in the Department of Health to ensure the implementation of the recommendations in this HIQA investigation report.
I thank the members of the Oireachtas Joint Committee on Health and Children for inviting us here today. I look forward to their questions.