The Health Information and Quality Authority (Hiqa) report into patient safety is sobering and disturbing . Notwithstanding claims by the HSE that "much of the narrative in the report lacks context or balance", it is clear the deaths of up to eight babies in the maternity unit at the Midlands Regional Hospital, Portlaoise, are emblematic of widespread lapses in patient safety at a local and national level.
Reading the experiences of parents of the deceased babies is harrowing: not alone had they to contend with sub-optimal care of their unborn leading to oxygen deprivation and avoidable death, but the manner in which parents received their dead babies, described as “grossly inappropriate and extremely traumatising”, has no place in modern healthcare.
It must be difficult for these parents and everyone living in the unit’s catchment area to hear Hiqa state that it is unable to “definitively conclude that services at the hospital are safe” for women giving birth. And to read of significant concerns about the safety of people attending the hospital’s emergency department. And to read of findings that question the viability of safe patient care across the entire hospital as Hiqa points to significant risks for those admitted under surgical, medical services and to intensive care there.
At a national level this seminal report must become a watershed for the administration of public health services. The HSE is now 10 years in existence; during that time it has been beset by recurrent system failures resulting in the unsafe care of patients and avoidable deaths. Despite solemn promises, the HSE has demonstrated that it is incapable of learning from previous mistakes.
Hiqa notes that: “previous investigations have highlighted serious deficiencies within the HSE in relation to its ability to learn from adverse findings”; and crucially finds that “six separate reports on other hospitals between 2008 and 2013 that should have led to improvements at facilities, including Portlaoise, were not fully acted on”.
The HSE’s threat to injunct the draft Hiqa report and its initial reaction to its findings lay bare a senior management modus operandi that shows more allegiance to self-preservation than to the optimum, safe care of patients in the public health system. The organisation’s directorate must now consider its position.
The late patient safety advocate and one-time contender for HSE chief, Prof Aidan Halligan wisely noted that "what we permit, we promote". Minister for Health Leo Varadkar has responded to the Hiqa report by noting patient safety came second to institutional, corporate and political interests. He may now have to step up to the mark and demand the resignation of those whose failure to carry out responsibilities clearly delineated in the Hiqa report represent a real and present danger to the health of every citizen in the State.