I propose to take Questions Nos. 86 and 124 together.
Since the publication of the Coroner's Inquest recommendations on 19th April last and the HSE's Report recommendations published on 13th June last, considerable work continues in addressing both reports' recommendations. A number of the Coroner's recommendations relevant to University College Hospital Galway (UCHG) were already being implemented in the hospital by the time of publication of the Inquest finding on 19th April 2013. Since the Coroner reported UCHG has undertaken the following additional measures:
- The education of all staff in the recognition, monitoring and management of sepsis and septic shock;
- The implementation of early warning scoring systems;
- The introduction of a new multi-disciplinary team-based education and training programme in the management of obstetric emergencies, including sepsis.
- Communications processes have also been improved and new procedures for doctors’ handovers will be implemented.
The interim recommendations made by the HSE Investigation Team in December 2012, relevant to UCHG, have been implemented at the hospital. The HSE has received assurance from the hospital that any immediate safety concerns have been addressed. The HSE established a National Oversight Group in March 2013 to advise and oversee implementation of the recommendations of the investigation; the group will also oversee implementation of the forthcoming HIQA investigation and the recommendations of the Coroner's investigation will be incorporated into their work. Prior to the incident in Galway, significant work had already been underway as part of ongoing clinical and patient safety initiatives within the wider HSE, including the HSE Clinical Programme in Obstetrics and Gynaecology, Anaesthetics and Critical Care which has been working on a number of national guidelines for Obstetrics and Gynaecology.
Other work which addresses the report recommendations includes:
- The launch of the first National Clinical Effectiveness Committee (NCEC)-endorsed National Early Warning Score guidelines for care of the deteriorating adult patient (NEWS) in February. The NEWS is being implemented in 87% of acute adult hospitals in Ireland
- A multidisciplinary education and training programme in I-MEWS (Irish Maternal Early Warning Score) which was rolled out across all 19 maternity hospitals in April and a clinical guideline developed
- National Guidelines have been developed on pre-term, pre-labour rupture of membranes; these have been disseminated to all maternity hospitals
- A Clinical Care Pathway for the care of the critically ill pregnant woman is currently being finalised
- The HSE has established a working group to improve communications between all staff and disciplines in the management and handover of patient care and to develop, implement and audit compliance with guidelines in line with the Royal College of Obstetricians and Gynaecologists Guidelines on the ‘Responsibility of the Consultant on Call’
- The HSE will develop a national guideline setting out the correct procedures for the follow up of patient tests in hospitals
- Additional counselling services have been put in place in GUH and the requirement for such services for women and husbands/partners following miscarriage and other serious incidents during pregnancy is being communicated to all 19 maternity hospital units; an initial review of current services has been undertaken
- An audit of compliance with HSE Standards and Recommended Practices for Healthcare Records Management has commenced
- A number of working groups will be established to scope out and develop detailed work plans to implement the remainder of the recommendations. The Report's recommendations will be implemented on a phased basis with the most urgent work being prioritised for Phase 1 (April to December). The time line for completion of Phase 2 actions will be agreed in Quarter 3 of 2013 and submitted as part of Service Planning for 2014.
With the Chief Medical Officer (CMO) I met Prof. Robert Harrison, Chair of the Institute of Obstetrics and Gynaecology, on 19th June, to discuss the significant general obstetric and gynaecological professional practice issues across the wider acute maternity hospital services which have been raised by the Report, in order to determine how the Department and the Institute may collectively address them In addition, the CMO has written to the Medical Council and An Bord Altranais seeking each organisation’s early consideration of the HSE’s Report in the same context as above and their advice on any recommended actions deemed appropriate. I wish to assure the deputy that my Department and the HSE will follow up in implementing and developing all the recommendations of both the Coroner's Inquest and the HSE's Report in to Ms. Halappanavar's tragic loss in order to minimise the risk of such an event happening again.