I thank the Ceann Comhairle and the Deputy for their agreement.
I am conscious of the personal tragedy for the family at the centre of this sad incident and am very anxious not to intrude on its privacy. I would like to express my sympathy to the family concerned on the sad loss of their child.
I am advised that following an obstetric clinical incident in Cavan General Hospital in 2012, an external review was commissioned by the Health Service Executive area manager. A team from the National Maternity Hospital was identified to carry out the review of the circumstances surrounding the clinical management and care of an obstetric patient and her baby. The review team met with the family and has taken its views on board and these views will be included in the overall report of the team. I am informed that a final report from the external review committee will be submitted to the HSE in the coming weeks. The general manager of Cavan General Hospital will liaise with the family concerned.
My Department is ensuring that the actions required to implement the recommendations in the HIQA report into the death of Savita Halappanavar at University Hospital Galway are being undertaken across our health services, with a view to improving patient safety and providing a more patient-centred model of care. A second progress report by the HSE's national director of acute hospitals, who has been assigned responsibility for this body of work, was forwarded to my Department on 2 May. Progress in implementing both the local and the national recommendations is well under way and will continue throughout the year.
Following on from the authority's report I have listed five key priorities in regard to patient safety. Patient safety has been made a priority within the HSE’s annual service plan through specific measures focused on quality and patient safety, including health care associated infections, medication safety and implementation of early warning score systems. Officials of the Department of Health will meet the HSE each month to review progress on the service plan and patient safety will be a standing item on that agenda. My Department is leading the development of a code of governance which will clearly set out employers’ responsibilities in regard to achieving optimal safety culture, governance and performance. It is expected that a code of governance will be developed during 2014. I have written to the Chairman of HIQA to ensure that my patient safety priorities are included in the monitoring programme against the national standards for safer and better health care. My Department, in conjunction with the HSE, will develop a new national maternity strategy this year. This will provide the strategic direction for the optimal development of our maternity services to ensure that women have access to safe, high quality maternity care in a setting most appropriate to their needs; and I have instructed the national clinical effectiveness committee to commission and quality assure four priority national guidelines on sepsis, clinical hand-over, maternal early warning score and paediatric early warning score. This body of work is in progress.
I requested the chief medical officer of my Department to prepare a report following a "Prime Time Investigates" programme relating to Portlaoise Hospital maternity services on 30 January 2014. The critical question the report addresses is whether the service provided by Portlaoise Hospital maternity services can be said to be safe from now on and into the future given the events that were reported in public and Portlaoise Hospital's response to these events.
Among the overall conclusions of the report was the conclusion that families and patients were treated in a poor and, at times, appalling manner with limited respect, kindness, courtesy and consideration. In addition, the Portlaoise Hospital maternity service could not be regarded as safe and sustainable within its current governance arrangements as it lacks many of the important criteria required to deliver on a stand-alone basis a safe and sustainable maternity service. An urgent recommendation was that the Portlaoise Hospital maternity service should become part of a managed clinical network under a singular governance model with the Coombe women and infant university hospital. Pending implementation of this recommendation, the report recommended that a team should be appointed to run the Portlaoise Hospital maternity service. The HSE put this team in place on 28 February last. On the broader maternity issues, it was recommended that other small maternity services should be incorporated into managed clinical networks within the relevant hospital group.
I also requested HIQA to undertake an investigation in accordance with section 9(2) of the Health Act 2007. In addition, HIQA was asked to undertake an immediate assessment of the patient safety culture at Portlaoise Hospital. Wider patient safety recommendations include the introduction of a patient safety statement for services which will be published and updated monthly and the establishment by HIQA of a national patient safety surveillance system. The Board of HIQA has approved the commencement of a section 9 investigation, and published its terms of reference for same on 18 March. HIQA announced the external members of the investigation team on 28 April. The report makes 42 recommendations and 11 overall recommendations, all of which I have accepted. This report will not only inform, but will underpin my Department's planned national maternity service strategy which will be delivered this year.
I take this opportunity to thank Tracey Cooper for her seven and a half years as CEO of HIQA. She is leaving us to return to her native Wales and I wish her well.
The HSE has considered the implications of the report and an implementation group, chaired by the national director of acute hospitals, has been established to oversee and ensure the recommendations of the report are progressed in a timely and effective manner. Progress on implementation of the recommendations will be reviewed by the HSE leadership team at its monthly meetings and a monthly report will be provided to the chief medical officer, CMO. The CMO received the second progress report last week and notes the continued progress in implementing its recommendations.