Review reveals Portlaoise failures
Grieving parents of dead babies faced grossly inappropriate and traumatising practices in a hospital, a damning health watchdog review has found.
In Portlaoise Hospital, where a number of babies died in controversial circumstances, mothers and fathers received the remains of their newborns in a metal box on a wheelchair covered with a white sheet and pushed by mortuary staff.
In one case the box was not big enough and the dead baby boy was squeezed in, the Health Information and Quality Authority (Hiqa) revealed.
Describing a harrowing picture of the treatment of grieving mothers and fathers and a lack of empathy from staff, one baby's mother told investigators she did not remove her son from the box or hold him for fear of not being able to return him to it.
Another reported how hospital staff told her the practice was in place to stop mothers becoming upset and others revealed how keepsakes of their babies were either not given back to them or returned incomplete.
In its report on the standards in Portlaoise, Hiqa said the lack of quality of care and infrastructure in the hospital, including issues raised in several reviews and reports going back to 2006, was putting patient safety at risk.
Patients and families who suffered loss in the maternity unit in Portlaoise had their fears, grief and upset compounded by medics' lack of empathy, unexplained jargon and feelings of intimidation.
Some parents recalled being sent to the mortuary alone, unable to follow directions and left to walk corridors looking for it.
Hiqa heard how years after the death of one baby the child's parents were telephoned to ask how they wanted their baby's tissue disposed off - despite neither of them giving consent for the hospital to retain it.
"The experiences outlined by patients and families during the course of this investigation were disturbing when viewed within the context of the delivery of a modern health service," Hiqa said.
"These experiences highlight significant deficiencies in the delivery of person-centred care at Portlaoise Hospital.
"Poor experiences by patients and families were compounded by ineffective governance arrangements at all levels of the HSE with the result that the patient's voice was ignored and valuable insights and learning to inform better care was lost."
The lack of empathy was again highlighted by a mother who lost a child but was reprimanded for crying on a ward with a medic telling her it would upset other mothers who had delivered healthy babies.
In another instance staff avoided going into a grieving mother's room after her baby had died.
Fifteen parents or family members met Hiqa inspectors over their treatment in Portlaoise with some recalling the first they knew of a death was seeing the newborn's body on a table.
Some said they were told their baby had been stillborn or d ied instantly at birth but documentation or reports obtained at a later date revealed conflicting i nformation - a source of great distress and shattered trust , Hiqa said
Portlaoise maternity services are being amalgamated with the Coombe Women and Infants University Hospital in Dublin as a result of the damning inquiry, an idea first proposed in 2006.
Hiqa found the hospital was unsafe.
"This investigation concludes that Portlaoise Hospital was allowed to struggle on despite a number of substantial governance and management issues in relation to the quality and safety of services," it said.
Some families reported staff using unexplained medical jargon which left them feeling intimidated and confused.
Hiqa said that based on the experience of grieving families there was an apparent lack of skill and sensitivity among some staff, including management, in communicating sensitively and empathising with people.
It found insufficient action by the Health Service Executive (HSE) at a national, regional or local level to address concerns highlighted in a raft of reports over eight years.
Hiqa said the review demanded accountability and called for a named manager to implement its recommendations and for Health Minister Leo Varadkar to appoint someone to oversee the work.
In one withering assessment the Hiqa report found HSE management were more concerned with controlling spending than monitoring risk.
Management were more focused on counting staff rather than on the type of service the hospital should be delivering and the type of staff needed to do that, it said.
Hiqa said increasing pressure on the maternity services at Portlaoise was highlighted as far back as 2004 and deficiencies in midwifery staffing were identified in 2006, while A&E clinical governance was unsatisfactory and overcomplicated.
The intensive care unit was not fit for purpose, Hiqa said, and did not meet the minimum requirements for critical care, patient confidentiality and privacy.
Hiqa said that in the seven years to 2014 health chiefs knew of actual or potential risks in the maternity services at Portlaoise based on the number and scale of medical negligence claims being made.
But there was no evidence that they took control of concerns after 2013 that local managers were struggling to deliver a service.
Investigators found Portlaoise management classed the hospital a Model-3 - offering acute care for all injuries and illnesses, including life support, but in reality it was not governed or equipped to do so.
They said the HSE failed to resource it sufficiently and ensure the proper governance to deliver such care to patients.
Up until July last year the A&E was open 24/7 but only had a consultant on site for six hours on four days a week.
Hiqa added: "The authority and investigation team wish to convey their sympathies to those affected by the events which gave rise to this investigation, and to express their gratitude to the people who contacted or who met with the Authority as part of this investigation."
Later, Mr Varadkar said: "I want to join with Hiqa in recognising the courage and fortitude of the patients and parents who shared their stories, and who have given us an opportunity to learn from the past and put things right for the future. We would not have this report without them.
"It's clear to me that, on occasion, patient safety and quality came second to other interests: institutional, staff, corporate and political. This has to change, not just in Portlaoise but nationwide."
Mr Varadkar called for a nationwide response to make sure the same mistakes are not repeated.
The HSE director general Tony O'Brien said : "The HSE has already acknowledged that there have been failings at MRHP (Portlaoise) over the years. The HSE has in the past apologised for these failures and the distress that they caused to the families concerned. The HSE restates that apology once again today."
But the HSE accused Hiqa of presenting some findings from an overly simplistic viewpoint and refusing to acknowledge exceptional challenges of seeking to maintain and manage services in the face of huge cuts.
It also claimed much of the narrative in the Hiqa report lacks context or balance.
It said some staff were not given an appropriate opportunity to contribute to the investigation and accused Hiqa of a lack of fair procedures.