The way in which the State’s maternity services are currently arranged and governed is not “sustainable”, an independent review carried out for the HSE says.

Former NHS executive David Flory reviewed services at two of the State’s smaller maternity units, Cavan General Hospital and South Tipperary General Hospital in Clonmel, at the request of the HSE.

In his report on Cavan, Mr Flory states there is “a general acceptance amongst those interviewed as part of this review process that the current configuration and governance structure for maternity services across Ireland is not sustainable.”

He says the “absence of a widely owned and understood strategic plan” allows for speculation and suspicion about what may happen, particularly to smaller units, in the future.

“This creates a negative environment which absorbs energy which can be better used focussing on day to day service delivery.”

The reports say smaller maternity units cannot operate in isolation and should share staff and facilities in order to provide sustainable services to their local populations.

The development of networks of maternity units needs to be fast-tracked, Mr Flory adds.

In a finding applicable to other smaller maternity units, he says they cannot sustain the breadth and depth of services without formal links and networks as part of a “bigger, stronger, more specialist units”.

Mr Flory’s report on Clonmel is strongly critical of gaps in management at the unit.

“Some parts of the building are not fit for the purpose of delivering high quality and safe care. The hospital is spending more than its income and yet suffers from shortages in key areas of the workforce.”

Mr Flory finds Cavan, where four baby deaths over the past three years are being investigated, has “a generally fit for purpose infrastructure overall and is quite well maintained”.

“As a consequence of these incidents there is a very bright and critical media spotlight on the hospital. This is impacting on the mood and morale of members of the maternity team and it was described how it is affecting clinical risk assessments and decisions.”

One locum consultant chose to leave the hospital because of these pressures, Mr Flory was told.

Although there is a midwife-led unit, this accounts for only 130 births in hospital out of a total of 1,800. “The doctors are very much in charge,” he comments, adding there is evidence the most senior midwife, an assistant director of nursing, is professionally isolated and unsupported.

“The hospital’s biggest challenge is coping with staff shortages in critical areas including obstetricians and midwives on the one hand and a committed level of expenditure in excess of available funding on the other hand.”

The HSE said the findings would provide important insights for considering “governance of quality, safety and risk in other maternity units and more generally across hospitals and hospital groups”.

“The reports acknowledge the challenges faced in recent years as a result of the economic environment and the impact this has had on staffing levels and the HSE’s ability to recruit to key vacancies both locally and nationally,” the HSE said.