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Things can and do go wrong in healthcare; the critical question for any healthcare organisation is how it reacts when things go wrong.
ON PAGE 58 of the Health Information and Quality Authority’s (HIQA) report into the safety and standards at the Midland Regional Hospital in Portlaoise is the sentence that encapsulates the whole report.
The report does not paint a picture of an endemically flawed institution, but one that did not have either the resources or know-how, or both, to deal with cases that went beyond the norm.
The reasons for this are debated. Governance expert Martin Turner said that he had “never seen an organisation as disorganised as the HSE,” saying that Portlaoise Hospital was either under-resourced for what it was being asked to deliver or over-valued for what it could actually achieve.
The HSE’s Tony O’Brien differed, saying that this was a case of resources. Speaking in a room overlooking Heuston Station some 90 minutes after the HIQA report was published on Friday morning, O’Brien talked about not being able to fill vacancies – figures show that one in six consultant jobs have received no applications whatsoever – , and of a health service changing and trying to get its house in order.
But, this was more than a failing of resources as Margaret Murphy, another of the HIQA investigation team said.
Resources don’t dictate whether a grieving mother is reprimanded for crying, or whether a child’s remains are stuffed into a metal box or whether the right time of death is given.
The report says that there were “opportunities to learn and change” which were missed and chances for this not to happen that were not taken.
Eight babies died
Following an RTÉ Investigations Unit report which aired on 30 January last year, the hospital set up a helpline for patients.
In the cases it examined, RTÉ found that “there were no congenital abnormalities, meaning the babies did not have a physical condition where their ability to survive was diminished resulting in death. Therefore other factors led to their deaths”.
The RTÉ segment was the catalyst for the 208-page HIQA report, but HIQA emphasises that this is not a resolution for the eight families who lost babies in avoidable circumstances.
A total of 83 patients contacted HIQA, some of whom described traumatic experiences while giving birth at the hospital.
Of those, the investigation team met with 15.
The patient experience
The HIQA team found that the experience of those 15 sets of parents was overwhelmingly negative.
Most parents recounted how difficult it was getting information and clarity on issues, they believed their questions were ignored and requests for meetings were avoided or refused.
Parents said that some staff were difficult to understand and possessed poor communication skills. This left parents feeling “intimidated”.
Women were not told about side effects of medicines and the volume on a machine to monitor heart rate was turned down.
Most parents told HIQA that staff were “uncaring” and didn’t listen. The lack of communication is called a “recurring theme” in the report.
As Professor James Walker of the investigation team said:
Portlaoise did not have a ‘phone a friend system’. There was a lack of teamwork and supervision. There was poor communication between staff.
Dignity and respect
In the section labelled “Dignity and respect”, the report outlines how parents who lost their children were treated.
The Investigation Team met a woman whose reported experiences reflected a lack of compassion, humanity, dignity and respect during her care. Another woman recounted that some staff made her feel like a naughty child or that she was a troublemaker when she questioned her care and treatment.
Another believed she was made to feel guilty for her tragic outcome and consequently this made her fearful of conceiving again. This fear of further pregnancy was a recurring theme among those parents who met with the Investigation Team.
Doctors routinely didn’t address patients and some parents were told sensitive information in public areas. One set of parents were told their child had died in a public corridor.
There were instances where a single member of staff showed kindness, but this was not considered the norm.
The handling of bereaved parents was also criticised, with one woman saying she was “reprimanded” for crying and another given her child’s remains in a metal box too small for his body.
Another set of parents received a phone call years after the death of their child asking how they wanted retained tissue to be disposed of, despite not consenting to the tissue being kept.
This, said investigator Margaret Murphy, went against the core principle of treating people with “the head, the heart and the hand”.
Moving on
The parents who contacted HIQA, did so to ensure that other parents did not have to go through what they did.
To stop this, HIQA has eight recommendations, ranging from the establishment of an independent patients group and “named accountability”.
While Tony O’Brien accepts the recommendations, he said yesterday that it was “too early” to talk about accountability. He and Dr Susan O’Reilly of the Dublin Midlands Hospital Group pointed to huge steps forward.
These include the filling of key posts, the establishment of hospital groups and more resources being diverted to the hospital.
Shauna Keyes, who lost her son Joshua, said that the report meant her family will no longer be ignored and families will be keen to see if the changes have any effect.
As Murphy put it:
To err is human, to cover up is inexcusable, to refuse to learn is truly unforgivable.
Originally published 7.10am
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Failure at every single level. Frontline to polished desk on the top floor.
Failure to the parents who placed their utmost trust.
Failure to the little lives lost, with so much potential.
But will anyone actually be held accountable?
No accountability and no action will be taken…other than retraining. Ireland seems to condone an acceptable level of ineptitude in everything from banking to health and who pays the ultimate price? We f***ing do!
“But will anyone actually be held accountable?”
Who was it once famously replied to a query from his accountant,when he was asking him if there would be a receipt for the 50,000 pounds being paid in cash to Ray Burke in his house in Swords:?
The reply is the same:
question.
“But will anyone actually be held accountable?”
reply.
“Will they fu*k.!”
When a whole system and way of working is flawed it’s difficult to pinpoint exactly who is accountable. Obviously people like consultants carry much of the responsibility as they dictate the pace, and much of the way a place runs revolves around their work practices (or lack thereof). It’s difficult though to account for a lack of empathy in these situations… maybe the midwives were spread too thinly but that’s not an excuse either…
It’s a culture within the system. When the managers signal they are ok with it, then lack of empathy and sympathy will thrive. You can bet no one is sitting back today saying “how can we be more empathetic and humane”. They are thinking “how do I cover my ass until this media storm blows over”. No lessons will be learned, a few will (perhaps) get a symbolic wrap on the knuckles to keep the masses happy and in a few days it will be a case of “move on nothing to see here”.
” It is hard to imagine a more stupid or more dangerous way of making decisions than by putting those decisions in the hands of people who pay no price for being wrong.”
Thomas Sowell
” one set of parents were told there child had died in a public corridor ” that sums it up really,forget about the medical negligence. Where is the bit of cop on and sensitivity that’s lacking ?? That cost nothing.
Just in case anyone thinks Portlaoise is the exception to the rule then they would be wrong. I was in Tallaght A&E a few years ago waiting on a trolley. Beside me was a man who was being told by doctors that he had terminal cancer and had only a few months to live. Tony O Brien says it’s too early to talk about accountability. It’s not. He’s running this circus and he should be first out the door. Don’t worry Tony. I’m sure you will still get a nice pay off and pension for the great work you have done.
As a parent of a baby that died I know exactly what it’s like to go through the experience,
Thankfully our hospital was the complete opposite.
That was a frightening article. The bureaucratic control and influence in the HSE needs to be dismantled. The covering up of responsibility for negligence is simply terrifying. There needs to be full accountability.
I had my 2 children here. It is grossly understaffed. When I was admitted in labour on my second, the midwife who admitted me told me she was leaving as she had been left as the only staff member on the maternity ward with 30 something mothers and 20 something babies because everyone else was in the labour ward.
I spent 26 nights there on my second pregnancy. The staff were great but it was unfair how stretched they were. I had to wait over 8 hours for drugs one day as they didn’t have enough staff to leave the ward to go to the hospital pharmacy. The heart rate monitors were faulty. They would beep for no reason and the staff would adjust it a few times but eventually tell you what button to push to silence it.
During one 9 night stint I was woken up during the night to be transferred to the surgical ward as there were no beds for the some in labour. While I was brought to the lift by the porter there was a queue of women in labour, waiting to be admitted to non existent beds. For the next 2 days in the surgical ward I was skipped from rounds as the maternity team had forgotten about me. When I finally got sent back up to the maternity ward I was told that my severe vomiting (hyperemesis) was something i should learn to control to during my lunch breaks and I was sent home as I had only vomited 4 times that day (by morning rounds) and I needed to be vomiting 6 times a day to be kept in. I was admitted 17 hours later, severely dehydrated and having vomited 18 more times.
The admitting doctor refused to give me anything but ordered a psychiatric consultation for me instead. This took over a day to arrive. When he arrived to my 7 bed ward, he called my name to look for me, (my bed number was on my chart. And on the board in the nurses station). He announced that he was from the psychiatric dept then closed the curtain. He asked if I had immediate feelings of self harm and when I said no he said “great, we’re very busy tonight, a colleague will see you tomorrow” and he left!
I’m so sorry you went through that Sandra, what an awful experience.
I’ll never forget my experience having my child there and with out sounding over dramatic with all their errors myself & my daughter where lucky to leave that place alive.
When will people be accountable in this country? Disgusting revelations and people need to lose their jobs over this and lose their pension. Yesterday we saw true democracy in action – three party leaders resigned after poor performance. But not in official Ireland. Land of nods and winks.
Holding people accountable is required. Not just to punish them but also to act as a deterrent to others.
Absolutely! I work in the public sector and I hate that some people who are utterly inept, incompetent and obnoxious are never reprimanded or better yet simply fired. If they can’t do a job due to lack of skill or qualification or want they shouldn’t be left to do that job. In this case, retraining will not be enough, not even close
One word Siobhan – unions
The HSE must have one mighty size carpet to push all there dirt under and move onto the next scandal.when does it all end and people for once being held accountable in this country
Never! Not the incompetent politicians (incompetence is actually a defence in this country it seems), not the bankers (and they still have nothing to loose if they go back to their wreckless ways again – all risk is on the borrower), definately not anyone in the HSE. It starts at the top and seeps down like a poison. Accountability? The most we can hope for is the odd sacraficial lamb (or even a report about the sacraficial lamb), but never EVER full and just accountability.
Mary Harney..remember her? Anyone?…im quoting now ‘we are closer to Boston than we are to Berlin’…creeping privatisation of health care system…profit vs people, simples. Consider your electoral choices very very carefully.
Sad,very sad for all concerned.
Is anyone in this country held accountable for anything?? Shameful.
In terms of accountability, Churchill once said, people get the governments they deserve…we elect them, its our call, accountability starts at the ballot box. Use your votes wisely. The best indicator of future behaviour, is, past behaviour. NO VOTES FF FFG LABOUR. OUT OUT OUT.
This is an absolute disgrace. The staff responsible need to be held accountable. Also how can the leadership team in the HSE remain in place. Anybody who attended meetings with the familys whose children died, must certainly join the dole queue.
This is what happens when our trust & confidence is misplaced. ‘Good enough’ is not good enough…a pauper statelet, a cowed down populace, drive to the bottom, lowest common denominator…an inevitable series of tragedies, the casualties mount up. Paying peanuts/get monkies. Cause & effect…welcome to 21st century Ireland.
It looks to me as if the HSE are doing a brilliant job diverting attention away for the dept of health and the minister for health. From a patients point of view it’s should be abolished but for a politicians point of view it’s the blueprint for all successful quango’s. As budgets were cut people blamed the HSE instead of those who cutting funding and closed hospitals. This government will not be electioneering on their record in health but on how with another 5 years the can “fix” our health system.
Gives you great confidence doesn’t it in the Irish healthcare system….bulls#it
I had my 2 children here and id rather have the next one in a ditch on the side of the road. I feel sorry for the people working here. It’s practically 3rd world. Never again, I can’t even bare to type the details and relive the trauma. Not to to mention 2 friends of mine who came home with no babies and the treatment they received. Appalling doesn’t cover it.
Who puts FF FG LABOUR in power, in whatever combo they hatch between themselves? ‘They’, ‘The Government’, ‘ The System/s’ are all voted for by the electorate. The book stops with every individual voter. If the electorate want change, then change your voting habits. No single transferrable votes. NO VOTES FF FG LABOUR. OUT OUT OUT.
Sure didnt fianna fail wreck the place……and our health minister is a lovely fella
I had an ectopic pregnancy and was admitted to portlaoise hospital as an emergency. The staff in a & e were lovely but when I was admitted to maternit pre surgery it all changed. The nurse I had to deal with was the cruelest most horrible woman I have met. While I was having a scan she talked about me to the other nurse but purposely loud enough for me to hear ” how can you be that stupid that you don’t know you’re pregnant”. She then put me in a corridor in a gown frozen, crying and bent in two with the pain by myself and vomiting and told me they will be down to take you to surgery when they are ready. A nice porter past me and came back with a blanket. After the surgery to remove the fallopian tube and foetus I was put on a ward with women and their newborns and any dealings I had with staff were cold and lacking any compassion. It was the worst experience of my life
HSE never heard of Six Sigma! … they need managers from best in class industry not from other Health Services.
A Six Sigma defect is defined as anything outside of customer requirements. Six Sigma is a process that must not produce more than 3.4 defects per million opportunities.
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