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Patient Safety Investigation Report published by Health Information and Quality AuthorityDate of publication:Wednesday, October 9, 2013
The Health Information and Quality Authority has today published the report of its investigation into the safety, quality and standards of services provided by the Health Service Executive (HSE) to patients, including pregnant women, at risk of clinical deterioration, including those provided in University Hospital Galway (UHG) and as reflected in, among other things, the care and treatment provided to Savita Halappanavar.
Commenting on the publication of the investigation report, HIQA’s Director of Regulation, Phelim Quinn, said: “The investigation findings reflect a failure in the provision of the most basic elements of patient care to Savita Halappanavar. They identified a failure to recognise that she was developing an infection and then a failure to act on the signs of her clinical deterioration in a timely and appropriate manner. The investigation also identified a number of missed opportunities to intervene in her care which, if they had been acted upon, may have resulted in a different outcome for Savita Halappanavar.”
He added, “Effective care and treatment depends on the regular monitoring and recording of a patient’s clinical observations and recognising their significance, acting appropriately on the findings, escalating concerns and the seamless clinical handover of information relating to each patient within and between clinicians and clinical teams.”
“However, during the course of the investigation, it was clear that the Hospital did not have effective clinical arrangements in place to ensure that this was done. Our investigation uncovered a series of failures in the management, governance and delivery of maternity services at UHG which were not consistent with best practice.”
Savita Halappanavar died as a result of sepsis and the Authority found no nationally agreed definition of maternal sepsis and also found inconsistencies in the recording and reporting of maternal sepsis.
The investigation also identified that there are a number of data collection sources involved in the collection of maternal morbidity and mortality data in Ireland, however, there is no centralised and consistent approach to reporting this.
The Authority’s investigation also found that there is wide variation in the local clinical and corporate governance arrangements in place across the 19 public maternity hospitals/units nationally. This means that it is impossible at this time to properly assess the performance and quality of the maternity service nationally.
There has been no national review, or national population-based needs assessment, undertaken to date to identify the appropriate allocation of resources including multidisciplinary workforce arrangements, or the models of care required to ensure that all pregnant women have appropriate choices and access to the right level of care and support at the right time in Ireland.
The Authority believes that, in order to provide assurances that pregnant women are receiving safe, high quality and reliable care during and after their pregnancy, maternity services must collect, monitor and manage quality and safety performance measures to evaluate the performance of their clinicians and the outcomes for patients. These measures should be primarily focused on assessing quality and safety outcomes for patients.
One of the key recommendations arising from the investigation is the need for the development and implementation of a National Maternity Services Strategy which will move us towards a demonstrably high quality, safe and best practice model of maternity care across the country.
The investigation also uncovered significant deficits in how relevant learning, particularly in the areas of maternity services and clinically deteriorating patients, has been adopted and implemented locally and nationally following previous investigations and inquiries both within Ireland and internationally. The responsibility and accountability to ensure that this happens sits locally with the Boards and Executives of healthcare facilities and nationally with the HSE and other corporate bodies providing health services.
Phelim Quinn said “The findings of this investigation clearly show that where responsibility for implementation of learning is not clearly owned, then learning does not happen. This is demonstrated in the findings relating to the HSE inquiry into the death of Tania McCabe and her son Zach in 2007, the circumstances of which have a disturbing resemblance to the case of Savita Halappanavar. The fact that six years on from the Tania McCabe report, only 5 out of the 19 public maternity hospitals/units were able to provide a detailed status report on the implementation of the recommendations from that report is simply unacceptable.”
“Both senior managers within every maternity hospital in Ireland, and the corporate HSE, are responsible for implementing this fundamentally important learning and should be held to account in doing so.”
As a result of the findings of the investigation, the Authority makes a series of 34 recommendations that focus on the improvements required in the Hospital and across all maternity hospitals in Ireland, as well as at national level.
These recommendations include the need to review and improve maternity services in respect of the management of sepsis, clinically deteriorating pregnant women, patient choice, models of care and providing a suitably skilled and competent workforce that can deliver safe and effective care at any given time.
The Authority has also included a specific recommendation for the Department of Health to develop a ‘Code of Conduct’ for employers. This includes a code for managers that will clearly set out the behaviours and responsibilities expected in relation to achieving an optimum safety culture, governance and performance of an organisation. It should also include the duties and responsibilities in relation to the professional regulation of staff and the referral of healthcare professionals, where appropriate, to their professional regulators.
Phelim Quinn concluded, “The findings and recommendations from this investigation focus on the substantial and significant failures in the most basic care provided to Savita Halappanavar and also point to improvements that are required in the delivery of maternity services in Galway, and in similar hospitals nationally.”
“Most importantly, the Authority makes a series of recommendations that when implemented we believe will bring about the necessary changes to ensure and demonstrate that women are receiving high quality and safe maternity care across Ireland.”
Marty Whelan, Head of Communications and Stakeholder Engagement, HIQA
01 814 7481/ 086 244 7623, firstname.lastname@example.org
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