18 April 2008
Following consultation with Mrs. Tania McCabe's family, the Executive Summary of the report into the circumstances pertaining to the death of Mrs. Tania McCabe and her infant son Zach and its recommendations has been published and is available at the link below.
Executive Summary - Report into maternal and child death at Our Lady of Lourdes Hospital, 2007.pdf (size 75.1 KB)
In March 2007, following the death of Mrs. Tania McCabe and her infant son Zach at Our Lady of Lourdes Hospital, Drogheda, the Hospital Network Manager commissioned a review to examine the circumstances pertaining to their deaths. The review focused on the clinical management of both Tania and Zach and also examined to what extent
non clinical factors may have influenced the care she received.
The thrust of this investigation was to identify learning for the service so as to assist in the prevention of future possible tragedies and to improve the quality of care. It was also to provide the answers required by Tania's family. The Review Team identified two Care Management problems which were:
- A working diagnosis of ruptured membranes was not made during Tania's first admission to hospital
- Septic shock was not recognised/diagnosed following her second admission and caesarean section.
Representatives from the HSE have met with the family of the late Mrs. McCabe again this week and they have again expressed their sorrow for the loss they have experienced. The HSE also acknowledges the huge trauma that staff at the hospital have undergone.
Recommendations to deal comprehensively with the weaknesses identified are made and prioritized in the report. There are a total of 27 recommendations, of which 15 are high priority, eight are medium priority and four are low priority. The
HSE is committed to addressing the recommendations set out in the Review and progress has already been made in their implementation.
The Department of Women and Children's Health within Our Lady of Lourdes has embraced significant change over the last number of years - the number of consultants Obstetricians has increased from 4 posts to 7 posts, there are 6 consultant paediatricians. Three additional consultant anaesthetists were appointed in 2007. A consultant haematologist was appointed to the hospital in 2006. 22 additional midwives were approved. This has raised the approved staffing compliment from 66.8 wte midwives to 88.6 wte midwives with an additional 10 midwives in the Midwife Led Unit. Significant investment in recruitment has resulted in all but 6 of these posts being filled. This brings the midwife to patient ratio to 1:48. There are currently 6 midwives vacancies in the Maternity Department in Our Lady of Lourdes Hospital, Drogheda and efforts are currently being employed to address this.
Rosaleen Harlin, HSE Area Communications Manager,
Dublin North East
Tel: 046 9280576/ 087 8291416
Developments within the Maternity Unit - The Department of Women's and Children's Health, Our Lady of Lourdes Hospital, Drogheda up to 2007 and from 2007 to date
Activity within the maternity unit in Our Lady of Lourdes Hospital, Drogheda has increased by 123% over a 10 year period up to, and including 2007. This exponential increase in activity was driven by:
- The reconfiguration of maternity services within the Northeast (Kinder Review 2001)
- The development of a residential camp for asylum seekers in the Mosney centre, Co Meath in 2001, and
- An overall increase in population of 30.3 % in the Louth - Meath region between the years 2002 and 2006 (National Office of Statistics 2006).
During this 10 year period, leadership from key individuals (management and clinicians) within the Hospital and the region, contributed to staff employed embracing the challenges of both the additional patient workload and the significant reconfiguration and service developments. The reconfiguration and developments were in response to the concern regarding risk, and were inline with recommendations from independently commissioned reports specific to the service, National reports and International recommendations of best practice. (Review of Maternity Services within the Northeast 2001, A Risk Assessment of the Obstetrics, Gynaecology and Paediatric Services 2002, Birthrate Plus 2002, Improving Safety and Achieving Better Standards: An Action Plan for Health Services within the Northeast 2006, The Lourdes Hospital Inquiry 2006) .
Developments within the Service up to 2007:
The vision of the Kinder Review (2001) was to "develop a woman centered, quality service which is safe, accessible and sustainable". It promoted a regional approach to the delivery of a quality service and resulted in:
1. Development of Governance structures.
The Review promoted the appointment of lead clinicians to Obstetrics and Paediatrics. Currently within Our Lady of Lourdes (OLOL) there is a lead clinician appointed to the Department of Women's & Children's Health. The lead clinician is also the Network Director to the Women's and Children's Health Network. The network has regional responsibility for the strategic planning of services within a formal multidisciplinary forum and is in compliance with the vision for transformation of services within the Northeast. There is a lead clinician in paediatrics within OLOL and a network director appointed to the Paediatric network.
Internally within the organisation, there are weekly clinical governance meetings incorporating the multidisciplinary team from Obstetrics, paediatrics, and the departments of anaesthesia, operating theatre and pathology as required.
2. Development of Midwifery Led Units.
Midwifery Led Units (MLU) were established in Our Lady of Lourdes (OLOL) Hospital and Cavan General Hospital (CGH). The MLU in OLOL opened for bookings in 2004 and had first patient deliveries in 2005. The development of MLU's in OLOL and CGH are the only midwifery led units developed nationally.
3. Evaluation and audit
The opening of the unit coincided with the commencement of a randomised control trial (Midu study) in partnership with Trinity College Dublin. The study aims to compare patient outcomes and experiences in the MLU with patient outcomes and experiences in the consultant led unit. An economic evaluation of the MLU is also in progress with a report anticipated in the last quarter of 2008.
4. Regional development of clinical standards of practice.
The development of regional policies, protocols and guidelines for clinical practice was promoted inline with International standards of practice.
5. Operational Management
A Care Process Group was established within the region to enhance the multidisciplinary management of operational issues within the region.
6. Launch of the Consumer Group (Oct 2006)
A group of midwifery staff, medical and members of the public engage to identify service improvements, inclusive of the development of practice driven protocols and the production of patient information leaflets and mother and baby groups.
7. Information Technology
The implementation of an Information Technology system (management information system) to progress audit within the region was funded and a project management team established. This aimed to facilitate benchmarking against key performance indicators.
8. Risk Management:
Implementation of the NEHB Risk Management Plan and corporate risk Management plan (2002). Clinical Incident reporting introduced in 2003.
Developments within the Service from 2007 to date:
9. Governance structures inclusive of communication structures.
A review of the Hospital Management and Communication structures is in process. It is anticipated that this will enhance current management and communication structures and lead to the establishment of an Executive Management Board across the Louth - Meath Hospital Group. This reconfiguration lends to a review of structures at all levels, and an opportunity to reemphasis communication at all levels within the organisation and the multidisciplinary team.
The Department of Obstetrics and Gynaecology provides a regional service across three Hospitals. Strategic planning and service developments take place within the Clinical Networks, with leadership from the Network Director and onsite lead clinician. The focus is to deliver a safe service in line with delivering on competing service needs. (Kinder Report 2001, Teamwork Report 2006).
Additional antenatal clinics are scheduled to accommodate the increase in patient bookings. These take place in the evenings and over the weekends and are managed within current resources (staffing and equipment).
Communication is enhanced via multidisciplinary team meetings, scheduled weekly:
Clinical Governance Meetings:
- 1st week Peri natal mortality & morbidity meeting
- 2nd week Gynaecology case presentation & audit
- 3rd week Audit of specific outcomes or interventions as recommended by RCOG e.g. massive PPH protocol, Induction of labour, caesarean section documentation
- 4th week Birth outcomes from the midwifery led unit and the consultant led unit. Clinical incident review presented by Consultant and CNM 111 trained in root cause analysis.
- Maternity Department daily meetings which involve a review of all patient cases seen within the previous 24 hours and complete a plan of care for all patients for the next 24 hours
- Weekly Neonatal Intensive care Audit meeting
10. Staffing Levels
The enhancement of service delivery and service developments was planned in line with addressing the staffing challenges, reducing the number of locums and having permanent appointments and implementing staffing levels in line with recommendations from the literature, the professional bodies and in comparison to similar organisations nationally.
The number of consultants Obstetricians has increased from 4 posts to 7 posts over the last number of years, there are 6 consultant paediatricians. While the issue of appointment of locums to consultant posts has not been completely resolved there is generally a policy to ensure appointments are to permanent posts as soon as possible.
There are 8 consultant anaesthetists in permanent posts plus 4 locum consultant posts, three of whom were sanctioned following the Harding Clarke Report (2006). This has allowed dedicated consultant anaesthetist obstetric cover between 08:00 hours and 17:000 hours five days per week.
Twenty two additional midwives were approved. This has raised the approved staffing compliment from 66.8 wte midwives to 88.6 wte midwives (an increase of 33%) with an additional 10 midwives in the Midwife led Unit i.e. total complement of 98.6. Significant investment in recruitment has resulted in all but 6 of these posts being filled. This brings the midwife to patient ratio to 1:48. There are currently 6 midwives vacancies in the Maternity Department in Our Lady of Lourdes Hospital, Drogheda and efforts are currently being employed to address this. .
Going forward, 16 additional midwives who are due to complete their postgraduate midwifery training have expressed an interest in continuing to work in the unit.
An independent workforce planner has been engaged via the Network office to validate the staffing numbers versus activity and this is in compliance with the exercise already completed by the three Dublin Maternity Hospitals.
A Clinical Facilitator is due to commence employment in April of 2008. This individual will have responsibility of supporting and delivering on the comprehensive induction and clinical practice assessments introduced for all new staff during 2007.
An Audit Facilitator post was recommended following the Harding Clarke Report (2006). While this person was not in post by December 2007 and the HR circular may have implications for this post, hospital management are currently progressing the matter as a priority.
The Consultant Haematologist post has enhanced service delivery and has put a system in place to ensure 24/7 access to Consultant haematologist advice.
11. Regional Development of Clinical Practice Guidelines
The Regional Clinical Practice Guidelines group have developed guidelines on 16 priority aspects of clinical practice. This includes a policy on the management of a patient with ruptured membranes and is currently being rolled out across the region.
A review of Early Warning Scores has taken place by a multidisciplinary project group within the region. Education of staff has commenced and the documentation will be piloted across the region in June. This will encompass review of all patient documentation: i.e. records of fluid intake and out put/ recording blood loss etc.
A review of documentation available to patients on discharge has taken place. A plan will be put in pace to develop this documentation and consultation will take place with the consumer group.
12. The Midwifery Led Unit
Over 750 mothers accessed this service during 2007. 241 mothers had 100% of their perinatal experience managed in this unit under midwifery care alone. To date the service has been well evaluated from a qualitative perspective.
The results of the randomised controlled trail to compare patient outcomes in the MLU versus patient outcomes in the consultant led unit are anticipated within forthcoming months.
The results of the economic evaluation of this service will also be available in the last quarter of 2008.
13. Service Quality Improvements
The establishment of an Early Pregnancy Assessment Unit (EPAU). Patients have direct access and avoid emergency department attendances. Total attendances for 2007 were 4152 inclusive of 3482 attendances by appointment, 229 inpatients and 441 emergency admissions.
In 2007, Our Lady of Lourdes Hospital was awarded the Baby Friendly Hospital Award and the silver award for Breastfeeding. This award is promoted by the WHO and UNICEF and it recognises international standards of best practice relating to care of the mother, the baby and the workplace environment. To date over 19,000 hospitals worldwide have achieved the Baby Friendly status. Achieving this award involved putting in place major institutional and clinical practice changes required to promote, support and protect breastfeeding.
14. Implementation of the Management Information System
This system has "gone live" in all areas within Women's and Children's Health since February 2008. This will ensure there will be complete data collection for 2008 and that audit of activity and patient outcomes can conducted.
To date the Department of Women's and Children's Health within OLOL has embraced significant change. It has a focus on service quality improvement and is striving to achieve. To echo Justice Maureen Harding Clarke (2006), "much has changed, much needed to change and much has yet to change". It is within this context of increasing activity, challenges of competing resource issues that OLOL strives to achieve while keeping sight of the need for continuous change and quality improvement at the heart of planning and decision making.
Rosaleen Harlin, HSE Area Communications Manager,
Dublin North East
Tel: 046 9280576/ 087 8291416
Last updated on: 18 / 04 / 2008