Source: Eamonn Farrell/Photocall Ireland

Things can and do go wrong in healthcare; the critical question for any healthcare organisation is how it reacts when things go wrong.

ON PAGE 58 of the Health Information and Quality Authority’s (HIQA) report into the safety and standards at the Midland Regional Hospital in Portlaoise is the sentence that encapsulates the whole report.

The report does not paint a picture of an endemically flawed institution, but one that did not have either the resources or know-how, or both, to deal with cases that went beyond the norm.

The reasons for this are debated. Governance expert Martin Turner said that he had “never seen an organisation as disorganised as the HSE,” saying that Portlaoise Hospital was either under-resourced for what it was being asked to deliver or over-valued for what it could actually achieve.

HIQA's Martin Turner says that quality and safety are not high on the HSE agenda. #Portlaoise — Paul Hosford (@PTHosford) May 8, 2015 Source: Paul Hosford /Twitter

The HSE’s Tony O’Brien differed, saying that this was a case of resources. Speaking in a room overlooking Heuston Station some 90 minutes after the HIQA report was published on Friday morning, O’Brien talked about not being able to fill vacancies – figures show that one in six consultant jobs have received no applications whatsoever – , and of a health service changing and trying to get its house in order.

But, this was more than a failing of resources as Margaret Murphy, another of the HIQA investigation team said.

Resources don’t dictate whether a grieving mother is reprimanded for crying, or whether a child’s remains are stuffed into a metal box or whether the right time of death is given.

The report says that there were “opportunities to learn and change” which were missed and chances for this not to happen that were not taken.

Eight babies died

Prof James Walker, Mary Dunnion , Martin Turner and HIQA Chief Executive Phelim Quinn. Source: Sam Boal/Photocall Ireland

Following an RTÉ Investigations Unit report which aired on 30 January last year, the hospital set up a helpline for patients.

In the cases it examined, RTÉ found that “there were no congenital abnormalities, meaning the babies did not have a physical condition where their ability to survive was diminished resulting in death. Therefore other factors led to their deaths”.

The RTÉ segment was the catalyst for the 208-page HIQA report, but HIQA emphasises that this is not a resolution for the eight families who lost babies in avoidable circumstances.

HIQA says that there were 8 baby deaths at #Portlaoise and a number of women had traumatic experiences — Paul Hosford (@PTHosford) May 8, 2015 Source: Paul Hosford /Twitter

A total of 83 patients contacted HIQA, some of whom described traumatic experiences while giving birth at the hospital.

Of those, the investigation team met with 15.

The patient experience

The HIQA team found that the experience of those 15 sets of parents was overwhelmingly negative.

Most parents recounted how difficult it was getting information and clarity on issues, they believed their questions were ignored and requests for meetings were avoided or refused.

Parents said that some staff were difficult to understand and possessed poor communication skills. This left parents feeling “intimidated”.

Women were not told about side effects of medicines and the volume on a machine to monitor heart rate was turned down.

Most parents told HIQA that staff were “uncaring” and didn’t listen. The lack of communication is called a “recurring theme” in the report.

As Professor James Walker of the investigation team said:

Portlaoise did not have a ‘phone a friend system’. There was a lack of teamwork and supervision. There was poor communication between staff.

Dignity and respect

Source: Eamonn Farrell/Photocall Ireland

In the section labelled “Dignity and respect”, the report outlines how parents who lost their children were treated.

The Investigation Team met a woman whose reported experiences reflected a lack of compassion, humanity, dignity and respect during her care. Another woman recounted that some staff made her feel like a naughty child or that she was a troublemaker when she questioned her care and treatment.

Another believed she was made to feel guilty for her tragic outcome and consequently this made her fearful of conceiving again. This fear of further pregnancy was a recurring theme among those parents who met with the Investigation Team.

Doctors routinely didn’t address patients and some parents were told sensitive information in public areas. One set of parents were told their child had died in a public corridor.

There were instances where a single member of staff showed kindness, but this was not considered the norm.

The handling of bereaved parents was also criticised, with one woman saying she was “reprimanded” for crying and another given her child’s remains in a metal box too small for his body.

Source: Eamonn Farrell/Photocall Ireland

Another set of parents received a phone call years after the death of their child asking how they wanted retained tissue to be disposed of, despite not consenting to the tissue being kept.

This, said investigator Margaret Murphy, went against the core principle of treating people with “the head, the heart and the hand”.

Moving on

The parents who contacted HIQA, did so to ensure that other parents did not have to go through what they did.

HIQA recommends that an independent patients group be established, that a national maternity strategy be devised and "named accountability". — Paul Hosford (@PTHosford) May 8, 2015 Source: Paul Hosford /Twitter

To stop this, HIQA has eight recommendations, ranging from the establishment of an independent patients group and “named accountability”.

While Tony O’Brien accepts the recommendations, he said yesterday that it was “too early” to talk about accountability. He and Dr Susan O’Reilly of the Dublin Midlands Hospital Group pointed to huge steps forward.

These include the filling of key posts, the establishment of hospital groups and more resources being diverted to the hospital.

Shauna Keyes, who lost her son Joshua, said that the report meant her family will no longer be ignored and families will be keen to see if the changes have any effect.

As Murphy put it:

To err is human, to cover up is inexcusable, to refuse to learn is truly unforgivable.

Originally published 7.10am