Although the publication of the State Claims Agency (SCA) report into maternity and gynaecology claims is an important step in filling a significant information lacuna about the performance of the Republic’s health system, its detail is less than reassuring. A new national incident management system shows the best performing maternity unit reported having adverse events that were almost 12 times lower than the hospital with the highest rate of clinical incidents. It found that different hospitals reported incidents differently and that among the country’s four flagship maternity hospitals the incident rate in two of the hospitals was twice that seen in the other two.
The SCA acknowledges that variation in patient safety incident reporting exists nationwide and notes a lack of standardisation regarding reporting of severity of injury in relation to patient safety incidents. It says it anticipates “better quality and more consistent reporting will result from healthcare enterprises becoming more familiar” with the management system which was first introduced in 2014.
This questionable quality means the report details must be interpreted with a degree of caution. What is not in doubt, however, is that 75 “extreme incidents” causing death or serious incapacity were reported by maternity services last year. The baby died in 38 of these and the mother in four. As is sometimes the case in healthcare, not all of the incidents were avoidable.
Behind these statistics are tragic events that have resulted in suffering and trauma. One such family are the Molloys whose baby, Mark, died in the maternity unit of Portlaoise hospital following a failure by staff to recognise and act on signs of foetal distress. His parents finally succeeded in their aim of having the official inquiry by the Health Service Executive (HSE) into his death published last week. Although completed in 2013 it has taken 2 years for the HSE to make the report public.
Roisin Molloy said she and her husband were determined that the systems analysis review into her son's death should not be kept hidden away. "They provide an opportunity for shared learning – not just in the hospital where the baby died, but in all maternity units across the country." The Molloys' approach differs significantly from that of the HSE: it emphasised that the publication of the Portlaoise report was a once-off as it saw systems reviews "as tools for hospital management" that are, "not typically published".
The HSE’s restrictive approach to the open disclosure of information that could help prevent similar incidents in the wider health system is unacceptable. It contrasts sharply with the attitude of the SCA, which notwithstanding the poor quality of its information, has shared its 2014 data within a reasonable time frame.