Dáil Éireann Debate, Wednesday - 3 May 2017
84. Deputy Clare Daly asked the Minister for Health his views on the failure of Portiuncula Hospital to inform the parents of a baby who died in the maternity unit there (details supplied) of either the existence of a review into the care given to the mother and baby in the hospital or the conclusions of that review. [20627/17]
View answerIn November 2014 a quality and risk management process highlighted a potential problem in maternity services in Portiuncula Hospital, on the basis of a higher than expected rate of newborn babies requiring head cooling. In early 2015 an Expert Review Team chaired by Professor Jimmy Walker, Professor of Obstetrics and Gynaecology, University of Leeds was established. After the review was made public further examination of cases and contact from further families, 18 cases (that is, 16 families) met the Terms of Reference for the review.
The family, to which you refer in your question, were unaware of the 2011 review that had taken place in to the death of their daughter. They should have been previously informed and given an opportunity to be involved in the review. My Department notes that both Portiuncula Hospital and the Saolta Hospital Group have apologised unreservedly and fully to the family for the failures of care delivered that contributed to the likely preventable deaths of their two daughters.
Safeguards are now in place in Portiuncula Hospital with regular and on-going audits in the maternity unit and Saolta Hospital Group have advised that there are no continuing patient safety concerns. I am advised that the Final Report of the Review Group is due to be published in the next few weeks.
My Department is continuing to progress an ambitious programme of patient safety reforms. The new National Patient Safety Office, located in my Department, was launched by me in December 2016. I have directed this office to work on a range of initiatives, including new legislation, the establishment of a national patient advocacy service, the measurement of patient experience, the introduction of a patient safety surveillance system and extending the clinical effectiveness agenda. Within the programme of legislation, it is intended to progress the licensing of our public and private hospitals.
As the Deputy will be aware provision to support Open Disclosure which is included in the Department of Justice and Equality's Civil Liabilities (Amendment) Bill 2017 was recently accepted at Report Stage by Seanad Eireann. The provision which is designed to give legal protection/privilege for the information and apology made to a patient is in line with the legislation. This is intended to create a positive voluntary climate for open disclosure and will support the National Policy on Open Disclosure which was developed jointly by the HSE and the State Claims Agency.
The main provisions of the Open Disclosure legislation are to:
- ensure patients are informed when adverse events happen as soon as is practicable;
- assist in supporting appropriate patient care;
- increase trust between patients and their clinicians;
- create a safe space for staff to conduct open disclosure;
- support staff in managing adverse events; and
- improve patient safety and quality of care through organisational learning.
Open Disclosure and a strong culture of reporting of adverse events provide opportunities to learn, improve, address errors that have happened and apply the lessons to make the service safer for all patients.
The Health Information and Patient Safety Bill will include a provision that public and private health care providers must notify serious patient incidents (Serious Reportable Events (SREs)) occurring in their services to their relevant regulatory body i.e. the State Claims Agency, HIQA, the Mental Health Commission or the Chief Inspector of Social Services as appropriate. The provisions intended for patient safety incident reporting and clinical audit in the Bill will provide a comprehensive patient-centred approach to preventing, managing and learning from incidents. HIQA and the Mental Health Commission are at an advanced stage of development of Standards on the Conduct of reviews of Patient Safety Incidents which expand on the National Standards for Safer Better Healthcare.
The Health Information and Patient Safety Bill is currently the subject of Pre-Legislative Scrutiny by the Oireachtas Committee on Health and I understand that they, following a public consultation exercise, may report in May.
My Department is committed to introducing a national licensing system in hospitals which will provide a mandatory system of licensing for public and private healthcare providers. The Patient Safety Licensing Bill is focused on governance and accountability and will ensure that providers do not operate below core standards. Licensing is part of a phased approach to better regulation in the health service.
The Government is committed to the progressive development of our maternity services. Key building blocks are now in place to facilitate the provision of a consistently safe and high quality service; these include:
- The National Maternity Strategy;
- HSE National Standards for Bereavement Care following Pregnancy Loss and Perinatal Death;
- HIQA National Standards for Safer, Better Maternity Services.
In 2016, Ireland's first National Maternity Strategy was published along with the HSE's National Standards for Bereavement Care following Pregnancy Loss and Perinatal Death and HIQA's National Standards for Safer Better Maternity Services. Since December 2015, each maternity unit has published a monthly Maternity Patient Safety Statement as recommended by the Chief Medical Officer.
These developments represent key building blocks to facilitate the provision of a consistently safe and high quality service. In addition, the newly established National Women & Infants Health Programme will lead the management, organisation and delivery of maternity, gynaecology and neonatal services, strengthening such services by bringing together work that is currently undertaken across primary, community and acute care. The Programme will also drive implementation of the Strategy and oversee the establishment of maternity networks in each hospital group.
