Wednesday, 14 May 2014

Ceisteanna (5)

Caoimhghín Ó Caoláin


5. Deputy Caoimhghín Ó Caoláin asked the Minister for Health if a report has been prepared on an infant born at Cavan General Hospital in November 2012 who was subsequently transferred to a neo-natal unit at a Dublin hospital and died there; if the report has been presented to him; and when same will be published; and if he will make a statement on the matter. [21353/14]

Amharc ar fhreagra

Freagraí ó Béal (10 píosaí cainte) (Ceist ar Health)

I seek to establish whether a report has yet issued on an investigation undertaken into the tragic loss of a newborn life, following a C-section at Cavan General Hospital in November 2012.

I note the reply to this question is quite long. Therefore, in view of the unsatisfactory nature of having to cut the Minister off half way through on an issue such as this, can the Minister and Deputy Ó Caoláin agree that we will allow the Minister give the full reply and that we will take just one supplementary question? Otherwise, I will have to cut the Minister's response off half way through.

Would it be allowed into the record?

Yes, but if the Deputy wishes to hear the full reply, I am prepared to allow the Minister the time for it.

I believe that would be appropriate.

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.

I join the Minister in extending sincere sympathy to the grieving family once again. However, it was not at the request of the family that I tabled this question, but because another tragic outcome has presented at Cavan General Hospital in the past fortnight. All families in the dependent catchment, including all of counties Cavan and Monaghan, particularly all expectant mothers and women of childbearing age, are concerned to know what has happened. They want to know why these tragic outcomes occurred. They want to know that the lessons, if there are any, are learned and that the prospects of a further bad outcome are eliminated.

Having inquired into the status of the report into the November 2012 event, I have discovered this report is still in draft form and has not been signed off. Why does it take 18 months and more to establish the facts of such an occurrence? Given the facts may well inform future practice within the hospital, would it not be essential to ensure early completion of the investigation and report and the implementation of any recommendations that may be made? I and people generally are alarmed that another sad outcome, where a C-section was also involved, has now occurred and the report on the first incident has not yet been presented.

When will this report be completed and will it be published, even in redacted form? We do not want to encroach on the privacy of the family involved, but surely lessons can and must be learned. This is all about restoring confidence in the excellent staff in the maternity unit in Cavan General Hospital and the systems and processes they employ in the service they provide.

I refer the Deputy to my earlier statement that the family's views will be included in the overall report of the review team and that a final report from the external review committee will be submitted to the HSE in the coming weeks. I agree with the Deputy and share his concern that people would be reassured of the safety of the service.

To make a general point, we have an excellent service, delivered by excellent people, but they are people and to err is to be human.

What we have to put in place is a system that protects patients from human error because human error will always occur and will always be with us. This is why the outcome of this report is so important. It will serve to protect from further incidents of this type and, without being prejudicial, determine whether we can learn from this to ensure that similar things do not occur again or that the service becomes safer. For example, in respect of Portlaoise we know that reports were done and put on a shelf. Nothing was learned from them and the same mistakes were made repeatedly. Certainly, we do not want to see that occur again. I believe that with the introduction of hospital groups and the service being brought into a hub and spoke model we can have available the level of expertise that supports professionals and protects patients.

Will the report be published, even in redacted form, if necessary?

I have no issue with that. I will have to discuss it with the HSE. Certainly, it will be made available to the family, there is no question about that, and then, in conjunction with them, redacted, if it is to be published. I have no issue with that.