Tuesday, 23 July 2019

Ceisteanna (1752, 1753)

Micheál Martin

Ceist:

1752. Deputy Micheál Martin asked the Minister for Health the procedure of reviewing alleged malpractice in a maternity hospital; and if he will make a statement on the matter. [33979/19]

Amharc ar fhreagra

Micheál Martin

Ceist:

1753. Deputy Micheál Martin asked the Minister for Health if it is correct procedure for a maternity hospital to set up its own review panel to investigate when a case goes wrong; and if he will make a statement on the matter. [33980/19]

Amharc ar fhreagra

Freagraí scríofa (Ceist ar Health)

I propose to take Questions Nos. 1752 and 1753 together.

The Deputy may wish to note that in his Report on Perinatal Deaths in the Midland Regional Hospital Portlaoise (2014), the Chief Medical Officer recommended that national standards on the conduct of reviews of patient safety incidents should be developed. Subsequently in October 2017, the Health Information and Quality Authority published the National Standards for the Conduct of Reviews of Patient Safety Incidents. The Standards are directed at health services and aim to improve how services conduct reviews of patient safety incidents that occur in their services.

When the delivery of care falls below an acceptable standard and leads to a patient safety incident, the Standards note that such incidents should be managed in an open culture that learns from errors and that takes corrective actions to improve patient safety. Standard 15.7 envisages three levels of patient safety incident review depending on the severity of the incident and the potential for learning and improvement; namely, concise internal reviews; comprehensive internal reviews; and external independent reviews.

The HSE's Incident Management Framework 2018, which are based on the Standards, sets out the procedures to be followed to conduct a patient safety incident review. The Framework also provides that health services may commission different types of reviews with different levels of independence depending on the nature of the patient safety incident.

With regard to your specific query in relation to the review of incidents in maternity services, the HSE National Women and Infants Health Programme has advised that in the case of maternal death, the Programme suggests the appropriate composition of the review team to the hospital concerned. In cases of direct maternal death, the review team will be external to the particular hospital and the Hospital Group. Other significant adverse outcomes in the maternity service, should be reviewed at a Hospital Group level, maternity only, Serious Incident Management Forum. This is designed to deliver a level of externality to every maternity hospital/unit and every significant incident.