Investigations into Maternity Services in Ireland

13 October 2016  

Speaking Notes: Phelim Quinn

Colleagues I want to thank the INMO and the RCM for their kind invitation to address this All-Ireland Midwifery conference. 

As a registered nurse I have long admired and valued the work of midwives and over my career as a health visitor in Northern Ireland worked closely with my community midwifery colleagues in Belfast and managed the community midwifery team as a community nurse manager in the former Armagh and Dungannon Trust.  I also had the privilege of holding the role of Statutory Supervisor of Midwives in my post of Chief Nurse within the former SHSSB.  

Today’s conference is aptly entitled – “it’s all about the women” – HIQA’s involvement in maternity services to date has tended to have a focus on instances within Ireland’s maternity services that have gone wrong.  That means that at times services have lacked the necessary emphasis on how those services met the needs of the women they were supposed to serve. 

Today I want to look at some of the challenges that have arisen out of a number of investigations and reviews into Ireland’s maternity services.  At the same time I want to acknowledge some of the critical developments and learning that have been identified from that work.

At the outset I would want to point out that although some of seminal events and failures investigated by HIQA in recent years had their origins in maternity services, findings are not always confined to maternity services.   Our approach to these investigations and the subsequent recommendations has wider resonance in acute hospital services and the management and governance arrangements in place.

The next few slides tragically catalogue how patient safety incidents in maternity services undoubtedly focus the most tragic circumstances for young women and their families.

When we look across the last number of years some of the headlines highlight the tragic loss of young women and in a number of instances their babies.

My earliest days in HIQA in 2012 were marked with the setting up of the investigation into the death of Savita Hallapanavar in UHG. Unfortunately her tragic circumstances were closely followed by the events in Portlaoise, where there were a number of neonatal deaths. 

In addition, in the years since,  that list has been added to further with other instances of maternal and child mortality and other serious incidents in Cavan, Portiuncula and Drogheda. Some have been investigated by the HSE and others reported on through the Coroner’s courts.

Critically each of those incidents and investigations brings into sharp focus some of the significant service failures of the past  - as inevitably any assessment by a regulator or other review body would require a review of how past lessons and learning have been applied.  They include:

·         The death of Tania McCabe and her baby boy at Our Lady of Lourdes’s Hospital in Drogheda

·         The death, by medical misadventure of Bimbo Onanuga, who was seven months' pregnant, died at the Mater hospital after being transferred there from the Rotunda Hospital on 4 March 2010.

·         The death by medical misadventure of  Dhara Kivlehan who died in 2010 nine days after giving birth to her son Dior by emergency caesarean section at Sligo Regional Hospital.

·         The death by medical misadventure of Nora Hyland who died in 2012 within hours of undergoing an emergency C-Section at the National Maternity Hospital.

·         The HSE apology following the death of Sally Rowlette in February 2013 after giving birth at Sligo Regional Hospital

·         death by medical misadventure  of infant Killian Lally Doyle in May 2013 atOur Lady of Lourdes Hospital in Drogheda failed to diagnose that the infant was in the breech position resulting of severe oxygen deprivation during birth.

All of these deaths are undoubted tragedies for the families involved and their investigation by HIQA, the Coroner or the HSE have the undoubted benefit of hindsight.  However, what becomes critical in these instances is the evidence arising out of findings and how they can be applied for the purposes of learning and improving patient safety into the future.

We all have a contribution to make to that learning and improvement so I wanted to say something about what I believe HIQA’s contribution has been and should be as we move into the future.

Earlier this year we published our corporate strategy - we took considerable time to reflect on what we, as the State’s health and social care regulator, should do to add value to Ireland’s health and social care system.   Development of the strategy was based on our experience of reviewing and investigating the system over the last 9 years, but also on what we see as the current and future challenges facing us all. 

Essentially we believed that through our legal mandate and the skills and expertise of our teams we want to ensure that care is safer, that care is better.  HIQA also wants to ensure that decisions how care is planned and delivered is better informed by the outcomes of our work and that we can continue to provide the public and the users of our service with assurance on the quality and safety of care.  This is reflected in our strategy map and these aims are delivered through our various functions be they standard setting, HTAs or the regulation and monitoring.

In 2012 we launched the National standards for safer better care.

These standards were divided into 8 themes covering the dimensions of quality and an organisation’s capacity and capability to deliver on quality.   In doing so we believed that the standards presented to services a framework for good governance leadership and management.  The standards were aimed at being:

•         Implemented at all levels of the healthcare organisation.

•          In All healthcare services, settings and locations (excluding MH) provided or funded by the Health Service Executive (HSE).

–        e.g. hospital care, ambulance services, community care and primary care.

•         There were 45 standards presented under 8 Themes    

They describe how a service provides high quality, safe and reliable healthcare which is centred on the service user.

The standards are also aimed at:

•         protect service users from harm

•         improve the quality of health service provision

•         provide an assurance mechanism for healthcare service providers to check if they have relevant systems in place to ensure quality and safety standards are met

•         provide a quality improvement framework that facilitates health service providers to realise improvement goals.

        

Last year we published an analysis of our investigations and monitoring work.  This analysis included our work in respect of the maternity services that we investigated in recent years. The analysis was aimed at: Mapping all of the recommendations from investigations and reviews in the period 2009 to 2015. In that period 216 recommendations’ had been made across 5 investigations and 1 Review

The investigations and reviews included our work in:

·         Ennis

·         Mallow

·         Tallaght

·         UHG

·         Pre hospital emergency care, and

·         Portlaoise

One of the overriding findings from a number of these reviews and investigations has been the ability of service providers to take the findings of our work and apply it within the context of the national standards and apply it to their service.

Today I am talking to you as managers and practitioners involved in the day to day delivery of care.  The approach we have taken in our work is to ensure that the standards are applied across all levels within the service.  Be that practitioner level in a ward or in the community: - Critically we ask -  what is your patient experiencing from the application of the standards?  At middle management level – how are middle managers and senior clinicians ensuring that best practice occurs as a routine?  And at group or national level:- how are executives assured of the quality and safety of services  - what metrics and intelligence do they consider as part of that assurance.

In our recent analysis we tried to show an example of how we believe that there was an absence of response to assessments being made within the system that may have averted a circumstance occurring whereby a number of families had extremely negative experiences of a service.  The example outlines critical milestones within the journey of maternity services within Portlaoise Hospital, where findings at local or national level, if they had been attended to – may have resulted in a very different experience for women and their families from 2012 until the initiation of the HIQA investigation.  What I am saying they had the benefit of hindsight from the internal review work and the evidence that would inform foresight from the wider system – but failed to apply it.

So what did we find in our analysis of the review and investigation work?

 

•         Wide variety of services and settings

•         Most relate to concerns or indicators of risk in Q&S and patient experience

•         Lines of enquiry relate to NSSBHC*

•         Recommendations made at the level of the ward or department, at service or hospital level and at hospital group or national level

•         We found repeated poor analysis of relevant findings and recommendations – and their application across all services and settings

•         Despite what is sometimes asserted within services; not all findings indicate resource deficits (some do!)

 

This slide provides a summary of our findings as mapped against the national standards and the number of recommendations connected to individual standard statements. The most

frequently occurring  recommendations were against National Standards was in respect of  Standard 5.2. (Governance arrangements).  This related to 30 recommendations in total.

There were some limitations to our analysis:

Findings and recommendations identified in the investigation and review reports related mainly to the themes of Effective Care and Support, Leadership, Governance and Management and Workforce. This was primarily because the investigations and reviews focused on the systems in place to deliver high quality safe care rather than patient experience which would be more likely to reflect national standards from the other themes.

This does not take from the importance of the other national standards under the themes of Person-centred Care and Support, Effective Care and Support, Safe Care and Support, Better Health and Wellbeing, Use of Resources and Use of Information.

Our findings fall under a number of broad headings:

For example delivering a service model that reflects integrated care:

22 of the recommendations related to the model of care - this included a lack of clarity around the stated purpose and in some instances the limitations of the services being provided.  The services were not reflective of best practice or keeping pace with new and emerging evidence. 

 

A further 12 recommendations related to the integrated nature of the service – in some instances we found that the service was not reflective of the complex model of care across care setting and professionals, and at times there was an absence of a single point of accountability for coordination of care.  Disturbingly and relevant to today’s conference theme; there was an absence of partnership with service users throughout their care journey.

There were 6 recommendations related to user’s initial and ongoing care needs.  One dominant theme pointed to the need to treat sufficient numbers of cases to maintain clinical skills & ensure best outcomes.

 

When looking at the theme of governance there were 29 recommendations related to formal systems of governance.  11 of those recommendations related to management arrangements aimed at promoting safe, high quality care.  They included the requirement for:

 

–        Systems, processes & behaviours by which services lead direct and control their services to achieve their objectives

–        Correlation between effective governance systems and performance within and across services

–        Clear lines of accountability (inc. Professional bodies)

–        That management need to be connected at all levels – local/regional/national

–         

Recommendations relevant to workforce related to adequate systems for training and assessment of competence to meet the objectives of the service and ensuring that learning is connected to risk and is disseminated across and up and down organisational structures

A number of recommendations relate to healthcare being reflective of the national and international evidence base.

 

–        The requirement for care to be  reflective of emerging evidence

–        That the risks and benefits of practice is as much a responsibility for managers as it is for clinical & care staff

–        And the requirement for the Implementation of clinical guidelines/integrated care pathways/ care bundles

Finally there were a range of recommendations related to the how systems are monitored, evaluated & continuously improved this included a significant number of recommendations related to opportunities to identify & act upon opportunities for improvement;

 

–        That Performance monitoring essential

–        The requirement for data collection to determine whether standards and targets are being met

–         And that there is good quality information, within and between organisations

 

In preparation for today and in line with HIQA’s achievement of its strategic aims I reflected on what has happened as a result of our work in recent years: - I supposed I was reflecting on whether Ireland’s health and social care system is learning from these issues.   Of course I wanted to challenge myself and HIQA on how we are informing decisions.

Undoubtedly as a result of specific recommendations we have seen the National Clinical Effectiveness Committee develop and publish three national maternity service clinical guidelines these include:

·         The Irish Maternity Early Warning System

·         Communication (Clinical Handover) in maternity services

·          And the national clinical guideline on sepsis management.

It is vital that the implementation of these guidelines is monitored by services locally and at national level.

As a result of recommendations in both the Galway and Portlaoise reports we have seen he development of the new national maternity strategy.  This strategy embodies critical concepts such as:

·         the three levels of care within the services,

·          A Health & Wellbeing approach,

·         Access to safe, high-quality, nationally consistent, woman-centred maternity care;

·         Adequate resourcing  and

·         Strong and effective leadership, management and governance. 

I believe we are at a point where we need to see a strong commitment to its full implementation.

Earlier this week HIQA submitted to the Minister the new National Standards for Safer Better Maternity Standards. These standards developed over the last year are informed by national and international research and best practice; are aimed at improving the safety and quality and consistency of maternity services; written in a way that women can understand what safe, high-quality maternity care looks like and promotes practice that is up to date, effective and consistent with international best practice.  We look forward to Ministerial approval and launch of the standards into our national services.

Other critical initiatives that have been implemented include:

Ireland’s first ever National Patient Experience Survey;  This major initiative seeks to enhance the quality and safety of care provided to patients in Ireland by listening to the experience and feedback of those adults who have spent at least one night in a public acute hospital.  Whilst this major initiative will not look at maternity services in the first instance - it is hoped that its scope and remit will extend to Maternity and other services in subsequent years.

As a result of HIQA recommendations we also welcome the publication of National maternity reporting monthly safety statements and the national oversight group on implementation of HIQA recommendations.

But there is still more to do; it is obvious that the length of time taken to investigate Patient Safety Incidents is unacceptable; in some instances the process for their conduct remains ineffective and non-transparent.    Earlier this month HIQA published draft national standards on the management of patient safety incidents for consultation.  Their ratification and implementation is critical if services are to regain the confidence of women using our maternity services

In our investigations into critical incidents and service failure in Galway and Portlaoise we also sought the development of a Code of Conduct for employers and managers, Supporting legislation for the establishment of hospital groups and the establishment of an Independent Patient Advocacy Service.  3 years on these key recommendations remain “in development”.

In recent weeks HIQA made a submission to Oireachtas Committee on the future of healthcare in Ireland.  As part of that submission we asserted that as part of the wider strategic review, Government should consider the introduction of a robust national commissioning model.  In the context of maternity services I believe that such a model can have a positive impact on effective service provision, governance, financial efficiency and in improving the quality and safety of services.

Commissioning arrangements explicitly define and separate the roles of purchaser and provider of services; currently both of these functions are usually performed by the Health Service Executive (HSE).  An effective commissioning body is responsible for purchasing health and social care services from providers. Procurement is always based on an agreed strategy, assessed need, best available evidence of service efficacy, value for money, and the capacity and capability to deliver a safe and effective service. While cost is, of course, important, quality and the delivery of safe services should be the primary goals.

Commissioning frameworks can provide for national, regional and local procurement arrangements that are person-centred and address local needs. This facilitates a focus on the health and wellbeing of local people and on achieving the best possible outcomes within available resources. While procurement decisions are made locally, the service itself is delivered in the most effective, efficient manner, whether in the community or at a national level.

Local commissioning involves community and primary care professionals, people like you, and, most importantly, people who use services. This empowers them to become a partner in their care and exercise choice and control over their lives, a central theme of today’s conference.

A national commissioning model would contribute to effective medium- to long-term planning by gathering evidence of current and future service needs. It would also optimise service configuration based on sound strategic planning. The introduction of a standardised framework to commission services would help, by way of example with the implementation of national clinical care programmes and strategies such as the National Maternity Strategy.

It is undoubted and right that Ireland’s maternity services have come under significant scrutiny in recent years.  The list of significant service failures and tragedies involving young women and in some instances their infants has required us all within the system to stand back and reflect on what needs to be done – but more importantly to get on with it. 

Whilst I have been able to outline some significant steps in that journey to improvement much more needs to be done. 

I believe we need to see:

·         implementation of the National Maternity Strategy,

·         approval, dissemination and implementation of the National Maternity Standards for Safer Better Maternity services that have been developed in alignment with the strategy.

·         A mechanism such as robust commissioning model that not only drives improvement in service and financial performance, but helps in the delivery of the national strategy and quality and safety.

·         We need to see a commitment by service providers and clinical staff to ensure swift, robust and transparent investigation of patient safety incidents. 

·         We need to ensure that patients with concerns or worries have the support of an independent patient advocacy service. 

·         We need to ensure that women are at the centre of what we deliver in our maternity services.

 This will require commitment at all levels, whether that be at political, national, hospital and at practice level.  We need to ensure that the journey to safer better maternity care progresses in line with 21st century standards and to ensure in line with today’s conference title that those services are for and “all about the women”.