JointCommittee onHealthChildren

6th March2014

OpeningStatement

by

Ms.Laverne McGuinness

Chief Operations Officer and Deputy Director General

HealthService

GoodMorning Chairmanandmembersofthe Committee.

ThankyoufortheinvitationtoattendtheCommittee meeting. Iamjoinedbymycolleagues:

  • Mr.Ian Carter, National Director, Acute Hospital Services
  • Mr. David Walsh, Regional Director Performance and Integration

The HSE welcomes in full the findings and the recommendations of the report of the Chief Medical Officer (CMO), Dr. Tony Holohan, relating to perinatal deaths and related matters in Portlaoise Hospital Maternity Services (PortlaosieHospital) from 2006 to presently. As you will be aware the Chief Medical Officer prepared this report at the request of the Minister for Health, Dr. James Reilly T.D.

The report of the CMO recognises clear failures in how risk and patient safety was managed in PortlaoiseHospital during the period in question. The report concludes that under the previous governance arrangements, the maternity services could not be considered a safe and sustainable service. A new management team was put in place last Friday to address this matter.

The HSE accepts that there were significant shortcomings in the cases referred to in the report, particularly in relation to the level and quality of care afforded to the patients in question and to the sub-standard communications with their families. The staff of PortlaoiseHospital apologised unreservedly to any families who experienced care below the expected standard at the maternity services in PortlaoiseHospital over the past number of years.

On behalf of the HSE, I wish to, once again, repeat this unreserved apology for the failings in the care outcomes experienced by the families concerned, for failing to ensure that prompt incident investigations were undertaken. I also wish to apologise unreservedly for the unacceptable communications with the families at a time when they most needed honesty, compassion and kindness. The fact that timely investigations did not happen is unacceptable.

The report makes eleven overall summary recommendations and Mr. Ian Carter, National Director for Acute Hospitals has overall responsibility for their implementation.

In the case of the eleven overall summary recommendations, three relate to HIQA and eight to the HSE. Steps have already been taken by the HSE to implement these eight overall summary recommendations with three already implemented and work has commenced to progress the other five.

The HSE welcomes the involvement of HIQA in relation to three of the recommendations and looks forward to its input.

A new Management Team was appointed last Friday on an interim basis in order to run the service. This new Management Team consists of;

  • Mr. Michael Knowles who has taken up the position of General Manager at PortlaoiseHospital. Previously he was General Manager in NaasHospital.
  • Ms. Angela Dunne, takes up the post of Director of Midwifery in PortaloaiseHospital. She was previously the Assistant Director of the Coombe Women and InfantUniversityHospital.

ThisManagement Team will remain in place until a new governance arrangement is put in place for the Hospital.

Dialogue has already commenced with the Coombe Women and InfantUniversityHospital in order to provide support toPortlaoiseHospital in a collaborative working arrangement into the future.

The new governance arrangements will bring the appropriate vigour to maternity services in PortlaoiseHospital. This is essential to quickly restore any loss of confidence that has arisen amongst mothers, fathers and families and the wider community served by the hospital.

The report concludes that families and patients were treated in a poor and at times appalling manner with limited respect, kindness, courtesy and consideration.

The Director General of the HSE, Mr. Tony O’Brien, has recently written to all staff within the health services highlighting the importance of honestly communicating with patients and families. In this letter he stated that communication failures, such as those experienced by the families referenced in the report, “erodes public confidence in Health Services, lets down the public and lets down the service as a whole”. He asked all staff to address together the fundamental issues of culture, that lead to such communication failures.

In this regard, the HSE has recently published its policy on Open Disclosure. The policy ensures that services embrace and support an open, timely and consistent approach to communicating with service users and their families when things go wrong in healthcare.

The HSE shares the concern of the Chief Medical Officer regarding the promptness of incident investigation. An Incident Management Policy, which is currently being updated by HSE’s Quality and Safety Directorate, intends to reinforce the importance of speedy incident investigations.

Furthermore, the HSE is conducting its own Review into many of the concerns detailed in the report. While we await completion of this Review, the HSE wishes to make it clear that it will take appropriate disciplinary action against staff members should the Review deem that such action is warranted.

Finally, Chairman and members this report has revealed unacceptable failings and I want to reassure you and the community served by Portlaoise hospital that we will work with the new management and staff in the hospital to make sure that these failings do not happen again.

This concludes my opening statement and together with my colleagues we will take any questions you may have.

Thank you

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