The publication of a review commissioned by the Health Service Executive, following concerns raised by women in the aftermath of revelations about baby deaths at the Midlands General Hospital in Portlaoise, has made some useful recommendations. Chaired by Dr Peter Boylan, former master of the National Maternity Hospital, the review examined some 28 case notes from three hospitals covering the period from 1985 to 2013. While the majority of the cases referred to the clinical review team arose from care provided at Portlaoise, it also included patients looked after in Mullingar and Limerick. Some 14 reviews involved instances of stillbirth and neonatal death, while adverse outcomes including a case of cerebral haemorrhage and one of a child with cerebral palsy were also included. The review team identified 11 cases where possible issues related to quality of care arose and recommended that nine of these proceed to a full systems analysis review.
Among the Boylan group recommendations is that every maternity unit in the State put in place a formal system for auditing pregnancy outcomes on a monthly basis. This would facilitate a pattern of adverse outcomes to be identified in a timely fashion, so that appropriate action could be taken. The Master system in Dublin’s three maternity hospitals includes regular review processes and has proven to be highly effective.
From the perspective of grieving families, the proposal to provide them with the results of a review into their case within two months, subject to legal constraints, is welcome. And while it may be difficult for families to deal with, the review group’s suggestion that consent for postmortem examination be prioritised in cases of perinatal death will help provide exact reasons for a baby’s demise. A need for trained bereavement counsellors was evident from the Hiqa Portlaoise inquiry so it is no surprise to see this as a recommendation in the health records review. The Boylan report must inform the National Maternity Strategy promised by the Government in the wake of identified poor standards of obstetric care.