Dáil Éireann Debate, Tuesday - 14 May 2024
649. Deputy Róisín Shortall asked the Minister for Health the source of his advice in relation to 21 baby deaths (details supplied); if he or his source of advice had sight of the names of the 21 babies before a radio interview; if he is aware that this list has grown to 45 babies; and if he will make a statement on the matter. [21809/24]
View answerWhen taking decisions in relation to clinical matters the Minister for Health relies on advice given to him by clinicians with specialist knowledge of the area under consideration. In the matter of maternity and neo-natal care that advice is provided to the Minister by the National Women & Infants Programme in the Health Service Executive (HSE), who have access to the highest level of clinical expertise in this area, and the National Patient Safety Office (NPSO) in the Department of Health who manage patient safety issues across the full range of care provided by our health service. In this instance, two issues were considered together in advising the Minister.
Comprehensive and individual patient safety reviews and coroners’ reviews are conducted when required. In addition, there are significant and robust mechanisms which Ireland has in place to monitor the quality and safety of our maternity services. These mechanisms include data sources such as the National Perinatal Epidemiological Centre (NPEC) Reports and the Irish Maternity Indicator System (IMIS) that provide National Reports for National Women and Infants Health Programme (NWHIP). To clarify, these reports have not specifically identified trends in relation to baby heart monitoring. While trending data is one source of information and no specific trends are identified in the national reports this is not considered in isolation. It is also well recognised clinically that failure to adequately interpret a cardio-tachograph (CTG) is often cited as a contributory factor in adverse event reviews, and in some coroner’s cases. It is also acknowledged, nationally and internationally, that CTG is an imperfect tool, that there are variations in practice and as such should always been used in conjunction with other monitoring techniques, such as the partogram and the woman’s vital signs.
When it is recognised that there is potential for variations in practice, robust, evidence based national clinical guidelines should be developed along with training for staff to ensure consistent implementation. This is the approach that has been taken in Ireland to the interpretation of CTGs. The HSE is currently working on a comprehensive new guideline that will help to further standardise the process and will be incorporated into the training system.
