Investigation into the safety, quality and standards of services provided by the Health Service Executive to patients in the Midland Regional Hospital, Portlaoise

Terms of Reference:

Following a request from the Minister for Health in accordance with section 9(2) of the Health Act 2007, the Health Information and Quality Authority (the Authority) will investigate the safety, quality and standards of services provided by the Health Service Executive (HSE) to patients in the Midland Regional Hospital, Portlaoise. The Authority will investigate and assess how local, regional and national clinical and corporate governance arrangements are supporting safe care in Midland Regional Hospital, Portlaoise (the Hospital). This Investigation will be further to and cognisant of the report of the assessment1 made by the Chief Medical Officer. The Investigation will be carried out on the basis of the following Terms of Reference:

1. To assess the patient safety culture in the Hospital.
2. To investigate and assess how local, regional and national clinical and corporate governance arrangements provided by the HSE are supporting the safety and quality of services at the Hospital for general and maternity patients, identifying whether risks to patients in the Hospital’s models of service provision have been identified, assessed and mitigated. The Investigation will specifically include the:
   1.  Extent of serious adverse incidents at the Hospital
   2.  HSE’s actions, inactions and governance response to serious adverse incidents and dissemination of learning
   3.  Associated relationship and communication between the HSE and patients and families and their experience.
3. To investigate what measures have been taken by the Hospital and the HSE in the implementation of national recommendations from previous investigations and reports including but not limited to:
   1. Investigation into the safety, quality and standards of services provided by the Health Service Executive to patients, including pregnant women, at risk of clinical deterioration, including those provided in University Hospital Galway, and as reflected in the care and treatment provided to Savita Halappanavar
   2. HSE Midland Regional Hospital, Portlaoise Perinatal Deaths (2006-date).
4. If, in the course of the Investigation, it becomes apparent that there are reasonable grounds to believe that there are further or other serious risks to the health or welfare of any person or persons receiving services, the Investigation Team may recommend to the Authority and/or the Minister for Health, that these terms be extended to include further investigation or that a new investigation should be undertaken, as appropriate.
5. The Authority shall, in good faith, prepare a report of the findings of the Investigation and make local and national recommendations as to the safety, quality and standards of services provided by the HSE, to the extent that the Authority considers appropriate. The report will be submitted to the Board of the Authority for approval. This report will be published in order to promote safety and quality in the provision of health services for the benefit of the health and welfare of the public.

This Investigation will be carried out in accordance with Section 9(2) and other relevant provisions set out in the Health Act 2007, as the Authority believes that on reasonable grounds there is a serious risk to the health or welfare of persons receiving services following consideration of, amongst other things, information and correspondence received from the Minister for Health and the HSE.

The Investigation will be conducted by an Investigation Team appointed and authorised by the Authority in accordance with Part 9 of the Health Act 2007. The Team will carry out the Investigation and may exercise such powers as it has, pursuant to Part 9 of the Health Act 2007, including rights of entry, its rights to inspect premises, records and/or documents and its rights to conduct interviews and rights to require explanations in relation to documents, records or other information. In addition, the Authority (with appropriate Ministerial approval and in accordance with the Health Act 2007 where required) may engage such advisers as it considers necessary in the undertaking of this Investigation.

In addition to the Terms of Reference for the Investigation above and in recognition of the wider, national issues highlighted in recommendation O.R.8 in the Chief Medical Officer’s report, the Authority will conduct a focused programme of monitoring of compliance with the National Standards for Safer Better Healthcare across maternity services nationally, pursuant to section 8(1)(c) of the Health Act 2007.

These Terms of Reference were approved by the Board of the Authority on 18 March 2014.