Portlaoise Hospital Inquiry - A Turning Point For Patient Safety?

By Cian O'Carroll, Monday, 11th May 2015 | 0 comments
Filed under: Medical Negligence, Hospital Acquired Infections, Personal Injuries.

The publication last week of the HIQA report into patient safety at Midland Regional Hospital, Portlaoise has the potential to mark an historic watershed for patient safety in Ireland. Were that to happen, no doubt it would offer some consolation to the parents and families of the at least 8 babies who needlessly died there in recent years. More importantly, it would see a shift in focus by hospital managers away from a budget-led approach which to date has seen the issue of patient safety and health outcomes receive little attention when key decisions about the health service are being made.

The HIQA report made many general findings relating to Portlaoise which I would summarise as follows:

  • Numerous reports have now been written on hospital safety in Ireland including 2 previously on Portlaoise yet the recommendations are being ignored and the same mistakes causing injury and death to patients are being repeated.

 

  • The experience of patients at Portlaoise shows in many cases a lack of compassion together with poor communication on the part of front-line staff which added to the harm that patients suffered where an adverse event occurred.

 

  • That local, regional and national HSE management teams are not effective in securing patient safety.
  • That management structures are poor. 
  • There were significant ongoing problems with workforce planning relating to Portlaoise Hospital. The absence of a clear vision for the hospital coupled with the national imperative to reduce the staff headcount ensured that workforce planning was focused on counting staff rather than on the type of service the hospital should be delivering and the workforce needed to deliver that service.
  • There was a poor safety culture in the hospital and while a Quality and Safety Executive Committee is in place, this Committee has approximately 20 different local committees reporting into it. In a hospital the size of Portlaoise Hospital, this committee structure was overly complicated and not effective.
  • The management team in the hospital did not analyse mistakes when they happened and so they were not learning from those mistakes nor did they have systems that would allow them to learn from such mistakes or ‘adverse incidents’.
  • That a national maternity strategy be published and implemented across the hospital system as a matter of urgency.
  • That up until late 2014, patient safety issues did not merit being a standard agenda item for discussion at senior HSE management level.

 

You get a sense that the investigation team and the report authors in HIQA are utterly frustrated by the ongoing and almost unrelenting failure of HSE managers to learn from either the mistakes or the reports of the past. They say “The HSE must now address the risks and deficiencies identified within this report in order to improve the quality, safety and experience of patient care in Portlaoise Hospital. It must also ensure that where similar risks and deficiencies exist in other hospitals, these are also addressed as a matter of urgency. The HSE at a national level must oversee the necessary improvements as part of its performance management arrangements.”

Depressingly, the first response of the HSE when this report was circulated to them in draft form last month was to threaten court injunction proceedings to prevent it being published. That does not appear to be the action of an organisation intent on reform but rather one of entrenchment and denial. Unless that attitude changes, it seems that this report and the likely reports to follow will continues to be like water off a duck’s back for HSE managers, both local and national.

At the same time as this report came out, we learn that the HSE sought additional funding from the Department of Health last year to create a system to analyse patient safety risks. In other words, they still don’t have a system to work out what the risks are and how to deal with them.

This all provides solid evidence for my contention, oft repeated here in these columns, that the HSE doesn’t care about patient safety because it is the patient who pays the price, not the HSE or its managers or its staff.

An obvious question arising from the HIQA report is whether Portlaoise is an isolated incident or do other hospitals present a similar threat to patient safety? The report is resoundingly critical of regional and national management structures as well as those local managers to an extent that it is inconceivable that the failures at Portlaoise are not repeated at other hospitals and that would certainly tie in with my experience through medical negligence practice.

So if this report is to be a watershed for patient safety in HSE hospitals, how do we bring that about? Clearly, the carrot approach has failed. 6 major reports on hospital safety have gone largely ignored by the HSE and as a consequence patients are dying and suffering major harm. I am convinced that it is time to try the stick. There must be accountability for such gross disregard to patient safety. If I run a transport company and I allow my trucks to go out on the road without proper maintenance, I will be criminally responsible when drivers or other road users suffer harm as a consequence. The same principle applies right across society from the workplace, to restaurants to banking. We must now ensure that healthcare managers are aware that where they fail to protect patient safety, they will be disciplined in the workplace and be exposed to criminal prosecution should loss of life or serious personal injury be attributable to their failure or negligence.

Sadly, in contrast to this suggestion, Tony O’Brien, HSE director general has responded to the report, not by firing managers, not even by seeking a disciplinary inquiry into their serial failures but rather by reporting two midwives to their professional body for disciplinary proceedings.

 

Cian O’Carroll Solicitors, A Medical Negligence & Personal Injury Law Firm. FREEPHONE 1-800 60 70 80 | WWW.TIPPLAW.COM

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