Patient safety investigation report published by the Health Information and Quality Authority

Date of publication:

The Health Information and Quality Authority (HIQA) has today published the report of its investigation into the governance and assurance arrangements that the Health Service Executive (HSE) has in place to ensure the safety, quality and standards of services provided to patients in the Midland Regional Hospital, Portlaoise.

Commenting on the publication of the investigation report, HIQA’s Chief Executive Phelim Quinn said, “This investigation was initiated as a result of the negative experiences of a number of patients and their families in receipt of services in Portlaoise Hospital. Their experiences highlighted significant deficiencies in the delivery of person-centered care at the hospital. This care fell well below the standard expected in a modern acute hospital. We would particularly like to pay tribute to the patients and families who made contact with the Authority to outline their experience of care within Portlaoise Hospital.

“Our findings point to failures, over a number of years by the HSE at a national, regional and local level to decisively address numerous clinical governance and management issues. This impacted upon the quality and safety of services provided at Portlaoise Hospital.”

Since 2007, the Authority has carried out six previous investigations into hospital care in Ireland and has made over 200 recommendations intended to be used by all healthcare services to inform and improve practice.

Phelim Quinn continued: “It is notable that local and national HSE inquiries and clinical reviews into patient safety incidents and significant service failures in Portlaoise Hospital were also carried out. Had the findings and recommendations of these inquiries and reviews been attended to, the Authority believes that the risks to patient safety and service quality could have been substantially reduced.

“Among the recommendations in today’s report is the creation of an independent patient advocacy service to ensure that patients’ reported experiences are recorded, listened to and learned from, and reports published. Lessons learned should be shared between hospitals within the new hospital groups, between hospital groups and nationally throughout the wider health system.”

The investigation identifies that the hospital viewed itself as operating as a model-3 hospital, one which provides the full range of acute services to patients presenting with all manner of injury and illness, including life support. However, services at the hospital were neither governed, resourced nor equipped to provide this level of care.

This was despite the fact that the HSE was in possession of information that indicated that its own clinical care programmes had expressed concerns about the quality and safety of acute and general medical services,paediatrics and surgery.

The investigation found that Portlaoise Hospital continues to provide undifferentiated surgical services where there are low numbers of complex surgical cases, despite the fact that two previous HIQA reports had identified clinical risks in these types of services.

The establishment of the hospital groups is a critical point in the modernisation of the Irish healthcare system. Portlaoise Hospital is to become part of the Dublin Midlands Hospital Group, although the formation of this group is at an early stage.  Work has already been carried out to incorporate the maternity services at Portlaoise Hospital into a clinical network with the Coombe Women and Infants University Hospital in Dublin, which is aimed at ensuring the networking of senior clinical leadership between the two hospitals.

Phelim Quinn added: “We believe that such a clinical network has the capacity to facilitate a common system of governance, the capacity for medical, midwifery and other staff to rotate between the two sites and more importantly, that the right patient is treated in the most appropriate clinical environment.

“As previously recommended, HIQA also believes that it is vital that a national maternity strategy is urgently developed in order to ensure that the profile and models of maternity services meets the needs of women across the country. We welcome the Minister’s recent announcement on the development of the Maternity Strategy Steering Group. In addition, HIQA, in conjunction with the relevant patient, clinical and professional organisations will develop draft standards for maternity services in Ireland for public consultation. These will be a part of the Authority’s National Standards for Safer Better Healthcare.”

In light of the findings of this investigation, the Authority has made eight recommendations which must be implemented to ensure that risks and deficiencies identified are addressed at both local and national level to ensure the delivery of safe and consistent patient care.


Further Information: 

Marty Whelan, Head of Communications and Stakeholder Engagement, HIQA
01 814 7481/ 086 244 7623,