Apparent deficiencies in care at portiuncula maternity unit

A HSE review of Portiuncula maternity unit is underway following the death of two babies and five more showing evidence of oxygen deprivation (hypoxia) during delivery last year.

The hospital is part of the Saolta University Health Care Group, which said this week the incidents occurred between February and November last year. The hospital group has put in place enhanced care processes and monitoring of women in labour at its maternity unit to address the quality of care issues that arose.

Saolta said it is satisfied that there is no continuing patient safety concern arising from the issues identified.

“On December 4 the Saolta Group mandated the implementation of corrective measures designed to address the quality of care issues that had been identified. Since then in repeated re-audits the hospital has confirmed the ongoing full implementation of the corrective measures.

“Additional training has been provided to all maternity staff and additional senior supervision is being provided to both medical and midwifery staff,” the hospital group said in a statement.

“There have been no negative perinatal outcomes at Portiuncula Hospital Ballinasloe since the enhanced monitoring measures were put in place.”
Apparent deficiencies in intra-partum care were identified which included interpretation and review of CTG tracings; administration of drugs to accelerate labour; and instrumental delivery.

The seven families affected are being contacted by the hospital and appointments made where requested for consultations with medical staff and support services.

In light of the initial internal review the families are being advised that their babies’ cases will be part of an in-depth review that has been initiated by Portiuncula Hospital Ballinasloe-Saolta University Health Care Group. The review will be conducted by an independent expert team and will include a patient representative. The seven affected families will be consulted on the terms of reference and the review team will engage with the seven families as part of the process.

The findings of the review will be made available to the families affected and will be presented to the HSE and the Minister for Health and his Department and will be published. It is expected this report will be available within approximately three months.

Saolta University Health Care Group added: “Portiuncula Hospital Ballinasloe-Saolta University Health Care Group regrets any distress this process may cause to the families involved and to other service users and in particular wishes to sympathise with the families of the two babies who died.

“Portiuncula Hospital Ballinasloe-Saolta University Health Care Group offer any services that they may require to support them in dealing with the issues that arise.”

Independent TD Denis Naughten welcomed the announcement of an independent investigation, but said he was disappointed that the parents of the babies involved were finding out about the inquiry through the media and not from the management of the hospital group.

“The internal review by the Saolta Hospital Group commenced 50 days ago and it is totally unacceptable that, only now, are the parents involved, being contacted. Surely, these parents have gone through enough trauma without having to read and hear about the inquiry before formal contact is made by the inquiry team,” said Deputy Naughten.

The local TD also cautioned that not only must the investigation be independent, it is imperative that it is transparent and seen to be independent of other medical agendas.

“Last year, the Saolta Hospital Group was forced to withdraw a plan which would have seen the maternity unit at Portiuncula Hospital, closed.
“Therefore, in the interest of the parents involved, the staff at the hospital and parents about to use the service, this investigation must be solely focused on what happened and what can be done to reduce the possibility of such serious incidents happening again.

“For those parents planning to avail of maternity services in Portiuncula, it is important to stress that the expected rate for neonatal encephalopathy, where a newborn’s neurological function is disturbed, is two per 1,000 births. The rate in Portiuncula last year was three. In 2013, there were two such incidents,” said Deputy Naughten.

“Furthermore, following an external review by Galway University Hospital, the hospital group is satisfied that there is no continuing patient safety concern arising from the issues identified.”