Sunday, 29 March 2015

The Coombe, Portlaoise, The Report and Managing the Media

Portlaoise Hospital www.

AIMSI was doing a media interview yesterday and we were asked by the radio presenter what our opinion was of the Minister of Health's response to the issues with Portlaoise, in particular with reference to the overtaking of services in Portlaoise by The Coombe Women's and Infants University Hospital.

Three days ago (25th March 2015) the Minister for Health, Mr Leo Varadkar  appeared on the Pat Kenny show on Newstalk national radio and made the following statements re the as yet unpublished draft HIQA report on Portlaoise hospital.
"It is a draft report. It's not a draft report that I've seen yet"
"The draft report hasn't yet been put to the board of HIQA. Like any draft report, on any matter, it needs to be fact checked and that's the process that's now underway. I do expect to see it in a couple of weeks and it will be published."
"The draft report casts the net very wide, not just making findings against senior management in HSE at national level but also front line staff at local level."
"The HSE would take the view that it has to defend the reputation and good name of its staff on the frontline."
"I don't want to see government agencies suing each other. I think it's not appropriate, it's a waste of money."
"I haven't seen the report yet so I'm not going to come down on any side until I have."
Minister Varadkar on Newstalk Radio with Pat Kenny 
The next day, Thursday March 26th we hear that a memorandum of understanding has been signed between the Coombe Women's and Infants University Hospital and Portlaoise Hospital to transfer governance as part of a  "managed maternity network", The implied message is that this a direct response from the Department of Health to the HIQA  (as yet draft and unpublished) report. How could this possibly have happened in direct response to the HIQA report when the day before the Minister of Health admitted on national radio that he had not even read the report?

The logistics required to make it such a response could not possibly have been implemented in 24 hours. Rather than a direct response to the HIQA report this was a cynically  managed media response to divert attention away from the spat between HIQA and the HSE, and the abhorrent failures within Portloaise itself. In fact this response coming in the first quarter of 2015, highlights another HSE failure, as these measures were recommended to have been in place by the second quarter of 2014.

The transfer of governance to the Coombe Women's and Infants University Hospital was recommended on the 24th February by the Chief Medial Officer based on the fact that it was ALREADY agreed government policy that this would happen based on the hospital trust policy.

The process was initiated on the 28th February 2014, when staff from the Coombe were initially transferred to Portlaoise Regional Maternity Hospital
"In a statement, the HSE said a new management team has been appointed on an interim basis in order to run the service from today.
The new team consists of Michael Knowles who is currently General Manager in Naas Hospital and Angela Dunne, currently the Assistant Director of the Coombe Women and Infant University Hospital.
The National Director for Acute Hospitals, Ian Carter, said “the new governance arrangements will bring the appropriate vigour to maternity services in Portlaoise Hospital.”"
This new management team wa  a result of the preliminary report to the Minister for Health relating to he issues that arose following a Primetime Investigates programme relating to Portlaoise Hospital Maternity Services on 30th January 2014.

The Interim Report to the Minister for Health Dr James Reilly TD From Dr Tony Holohan Chief Medical Officer on the 24 February 2014 on "HSE Midland Regional Hospital, Portlaoise Perinatal Deaths (2006-date)"stated that
"The overall conclusions in the Report are as follows: 1. Families and patients were treated in a poor and, at times, appalling manner with limited respect, kindness, courtesy and consideration. 2. Information that should have been given to families was withheld for no justifiable reason. 3. Poor outcomes that could likely have been prevented were identified and known by the hospital but not adequately and satisfactorily acted upon. 4. The PHMS service cannot 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. (See Overall Recommendation 3). 5. Many organisations, including PHMS, had partial information regarding the safety of PHMS that could have led to earlier intervention had it been brought together. 6. The external support and oversight from HSE should have been stronger and more proactive, given the issues identified in 2007. " p. 10
The recommendations of this report included the following
"Recommendation O.R.3: A team should be appointed to run the PHMS pending implementation of Recommendation O.R.4 below. Recommendation O.R.4: PHMS should become part of a Managed Clinical Network under a singular governance model with the Coombe Women & Infant University Hospital. Recommendation O.R.5: Other small maternity services should be incorporated into managed clinical networks within the relevant hospital group." p. 10
Overall recommendation 3 was expanded on:
"In this regard the HSE should immediately put in place a transition team to take control of the service at PHMS and to oversee the planning and execution of the orderly implementation of the managed clinical network recommended below. The transition team should consist of appropriate clinical and managerial expertise".  p. 69
Overall recommendation 4 was expanded on, and the report recommends implementation of this in the second quarter of 2014
 "The number of births at PHMS shows that there is and will continue to be a need to have a maternity service at Portlaoise Hospital which meets the requirement of good safety, patientcentred and sustainable care. A decision to close the service would not be appropriate given the scale of activity. Neither is it an option to maintain and develop the service under its current governance arrangements given the findings and conclusions in this report. Portlaoise Hospital is a constituent hospital of the Dublin Midlands Hospital Group. This Group also includes the Coombe Women & Infant University Hospital. The development of a managed clinical network within the Dublin Midlands Hospital Group, initially comprising the PHMS and the Coombe Women & Infant University Hospital provides a sustainable solution to the leadership, staffing, training, quality assurance, clinical standard and risk management issues identified in this report. The implementation of the Establishment of Hospital Groups34 will ensure that the future service needs of the whole population of each hospital group will be quantified and planned in a more integrated fashion. The overarching system of clinical governance and enhanced communication and cooperation between hospitals within the hospital group setting, will underpin the provision of quality and safe healthcare. The managed clinical network should consist of the following features:  A single clinical service under the governance, direction and authority of the Master of the Coombe. Capacity for medical, midwifery and other staff to be appointed to the network and to rotate as required by service and training needs between sites. Training for junior doctors and midwives to happen on both sites. Common system of clinical governance i.e. policies, audit meetings, quality assurance, incident reporting, incident management etc. with pooling of all data to ensure that all quality assurance is on the basis of one single service- albeit operating on two sites. Risk stratification of patients attending PHMS to ensure that higher risk pregnancies are dealt with at the Coombe site". p.69

Overall recommendation 5 was also expanded on and the report recommended implementation of this at the end of the second quarter of 2014
"This Report recommends the urgent transition of Portlaoise Hospital as the first smaller hospital to become part of a managed clinical network under the clinical governance of a larger hospital, in this case, the Coombe Women & Infant University Hospital. A managed clinical network with the features described above would provide a number of advantages for smaller units. It can provide clinical governance, leadership, shared clinical guidance, shared training and processes for rapid referral. In these circumstances, other small maternity services in the country should be incorporated into a managed clinical network within the relevant hospital group. Given the findings of this Report which are in part the result of small size and the challenge of sustaining services by attracting and retaining staff, it is considered reasonable that work commence on integrating smaller maternity units into systems of common governance in line with the planned hospital networks. It should not await the outcome of further analysis by HIQA which is recommended below." p. 70 
The report also made these observations
"In the preparation of this Report a number of issues of concern emerged through meetings with families and others. There were clear descriptions where patients felt backs were being turned; honest accounts were not given; and unprofessional behaviours and language were frequent. Insensitivity and a lack of empathy were common themes. Younger patients were not so much spoken to directly as through their mothers and had the feeling of being “judged” by staff. There were even accounts of senior clinical staff (more than one) inviting families to “sue”. There was also a lack of cultural sensitivity. These accounts were not just applicable to the PHMS but also to the paediatric unit." 
AIMSI are used to hearing these types of descriptions from service users of the Irish Maternity Services. Most health professionals prefer to keep their ears closed and believe that such reports are grossly over exaggerated. In fact many health care professionals feel that patients airing grievances with the maternity services should not happen in the media at all. Without the media, the alarming events at Portlaoise would never have come to light. We know that internal inquiries were carried out in Portlaoise with appallingly long time lags; averaging three years from incident to report. In one case the incident took six years to reach report stage. AIMSI will continue to liaise with the HSE whenever our input is welcome and appreciated. When it is not, we will continue to highlight lapses in care and safety in the media.

Our press release in response to the HIQA report is here

To answer the question; what is AIMSI s response to the managed maternity network between the Coombe and Portlaoise (as recommended in 2014). Our response is that this can only be a good thing. Our hope is that this will ensure adherence to the National obstetric guidelines, primarily with respect to CTG, and to the new guideline for the use of syntocinin in labour. We also hope that the ethos of The Coombe as a forward thinking hospital, looking to encourage midwifery led options for low risk women will also transfer to Portlaoise. Recent developments in the Coombe have included water births, DOMINO, early transfer home and midwife led antenatal clinics. They are also the first hospital to have initiated a doula policy in Ireland. On May 7th they will be hosting the 8th Essence of Midwifery Care Conference looking at Changes, Choices, Childbirth in which many of these changes will be highlighted. AIMSI will be speaking at the conference.Or more information on the conference see .

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