The HSE today (Thursday 22nd October 2015) published a report following a Systems Analysis Review into the death of Baby Mark Molloy who died in the Midlands Regional Hospital, Portlaoise in January 2012. This report is being published at the request of, and with the prior consent of the parents of Baby Mark. The Molloy family has also requested that Baby Mark's Cardiotocography (CTG) trace be published.
The report identifies a number of significant failings into the death of Baby Mark. The HSE reiterates its unreserved apology to the Molloy family for these failings and the distress and anguish caused to them.
The Systems Analysis Review undertaken in 2013 is a methodical investigation of an incident to allow management to understand the key causal factors contributing to an adverse outcome. The reports from such Reviews are tools for hospital management and as such, are not typically published. This report has been published at the request of the Molloy family. The HSE acknowledges the courage of the Molloy family for their consenting to the publication of this report.
While this report has been published two years after its completion, the findings of this report and its 43 recommendations have been implemented in the maternity services in Portlaoise and in other maternity units throughout the country.
Since its completion in 2013, the Systems Analysis Review (along with the subsequent HIQA report) has resulted in many improvements in Portlaoise Hospital's maternity unit including new management and governance arrangements; the development of quality safety and risk management structures; a formalised arrangement with the Coombe maternity hospital; the appointment of a Clinical Director to improve clinical integration on maternity services; and the appointment of additional midwifery and specialist nursing staff for maternity services.
This report has also been a key driver for the development of improved services in all maternity units throughout Ireland. Key developments in this regard include:
- dissemination of a number of key clinical guidelines relating to obstetric services including sepsis management, management of a critically ill woman, clinical handover, and management of miscarriage
- implementation in all hospitals of the National Early Warning Score (NEWS) and the Maternity Early Warning System (IMEWS) in the 19 maternity units
- launch of standards on bereavement services for families affected by adverse outcomes
- development of mandatory Cardiotocography (CTG) trace training
- establishment of Women and Infants programme and advertisement of key posts
- approval to appoint directors of midwifery to all 19 units to strengthen clinical governance and senior decision making in all of the units
- reporting by the 19 maternity units on 30 quality assurance indicators since August 2014
- development of maternity safety statements on a monthly basis with effect from October 2015
A National Implementation Group has also been established by the HSE to drive the agreed action plan arising from the Chief Medical Officer and HIQA reviews of Portlaoise . The Plan sets out clear milestones , timelines and accountable persons for delivering on the actions. The plan is also informed by the experience of the Molloy family with specific reference to a systematic approach to risk management, development of quality and safety structures, and whole system learning from adverse advents. In this context, the HSE welcomes the participation of Mrs Molloy in the National Maternity Strategy Steering Group established by Minister Varadkar.
These combined actions are intended to strengthen the delivery and oversight of Irish maternity services.
The proposed establishment of managed clinical maternity networks over the coming months will further augment the clinical governance and leadership within maternity units with the objective of delivering high quality patient centred services to women and babies.
Many families have been affected by adverse outcomes in our maternity services over the past number of years. The HSE deeply regrets the distress and anguish caused to these families for its failure to respond in a timely and empathic way to these issues. It is the Molloy family's expressed wish that the publication of Baby Mark's report will ensure that recommendations will be implemented nationally, inform the National Maternity Strategy and, most importantly, prevent unnecessary suffering, injuries and loss of life.
A systems analysis investigation of an incident (previously known as root cause analysis) is a methodical investigation of an incident which involves collection of data from the literature, records (general records in the case of non clinical incidents and healthcare records in the case of clinical incidents), interviews with those involved where the incident occurred and analysis of this data to establish the chronology of events that lead up to the incident, identifying the key causal factors that had an effect on the eventual adverse outcome, the contributory factors, and recommended control actions to address the contributory factors to prevent future harm arising as far as is reasonably practicable.