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Thread: Portlaoise Maternity Service Report - It's About Avoidable Deaths, Not Bad Manners

  1. #1
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    Default Portlaoise Maternity Service Report - It's About Avoidable Deaths, Not Bad Manners

    The HSE Report on neonatal deaths at Portlaoise in the Midland Regional Hospital was initiated in response to an RTE documentary, and seems to have been carried out very thoroughly and to a high standard.

    Uniformly, the media have reported this as being about the appalling manner in which families were treated.

    Hardly a mention anywhere of the clinical issues that led to deaths.

    The Irish Times has a useful timeline on page 3, but it is not online. I quote
    " March 2012: A review into the care of three babies - Katelyn (baby X)...Joshua (baby Y) and a third baby identified as baby z who survived - makes recommendations on CTG policy (monitoring of mother and baby during labour ) policy and training and on use of oxytocin (syntocinon) - a drug that artificially speeds up contractions."
    The Times also says that poor response to a deteriorating situation (as with Savita Halappanavar) was a problem.

    CTG and oxytocin have been used for more than 30 years - all maternity staff should be 100% using them correctly. In Portlaoise, even after poor practice was identified, it was allowed to continue and this appears to have cost more deaths. For six years from 2006, there were lapses in good practice in Portlaoise. The report says that risk management was managed from Tullamore, not from Portaoise. That can't have helped to ensure that bad practice was changed. I am sceptical that managing Portlaoise from the Coombe as is now happening, as a result of this report, is a good solution. A 2012 HIQA report showed that there were multiple management problems at Portlaoise, in terms of accountability of management, and drug management. The HSE report rightly said that there was ample evidence with the HSE that should have prompted intervention much sooner.

    I'm sorry about the brutal and offensive treatment that families had, as described in the report, but I expect they would have put rudeness by staff behind them had they been able to take their healthy baby home with them. This is about peoples' babies dying, not about staff manners

    http://www.irishtimes.com/news/ireland/irish-news/report-says-maternity-service-not-safe-or-sustainable-1.1708928

    From para 4.5 of the HSE report


    At several points in the assessment of care at PHMS, it became clear that there was a delay in acting on clinically significant signs and symptoms of the patient. At some points there was failure to recognise the deterioration of the patient condition such as the non-recognition of foetal distress evident on CTG monitoring18. This meant that escalation of care was not triggered due to failure to recognise that escalation was needed. At other times, even when the need for escalation of care was recognised and acted upon, either a misjudged clinical decision was taken such as the inappropriate use of oxytocin when labour was progressing with efficient uterine contractions or senior staff were not contacted or were unavailable for urgent review of patients who were deteriorating.
    Primary responsibility for the care of the patient lies with the medical practitioner or medical ‘team’. However an escalation protocol describes the supporting actions that must be in place for the management of all patients. It is the responsibility of each acute hospital service to clearly outline their escalation protocol. All escalation protocols should support the clinician at the bedside to escalate care until he/she is satisfied that an effective response has been made. The escalation process should be tailored to match the characteristics of the acute hospital setting. Consideration of the size and role of the hospital, the location, available resources and the potential need for transfer to another facility will all need to be accounted for in the escalation protocol. An example of a system of escalation of clinical care is the National Clinical Guideline (Early Warning Score) which was quality assured by the NCEC and endorsed by the Minister for Health in February 2013. The guideline is now implemented in all acute hospitals for adult non-pregnant patients.1
    Last edited by C. Flower; 01-03-2014 at 02:39 PM.
    “ We cannot withdraw our cards from the game. Were we as silent and mute as stones, our very passivity would be an act. ”
    — Jean-Paul Sartre

  2. #2
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    Default Re: Portlaoise Maternity Service Report - It's About Avoidable Deaths, Not Bad Manners

    Someone clearly told the HSE to treat it as a communications issue, and not a medical one

    The compliant media run with the official story
    Politics is the gentle art of getting votes from the poor and campaign funds from the rich, by promising to protect each from the other. ~Oscar Ameringer

  3. #3
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    Default Re: Portlaoise Maternity Service Report - It's About Avoidable Deaths, Not Bad Manners

    Quote Originally Posted by DCon View Post
    Someone clearly told the HSE to treat it as a communications issue, and not a medical one

    The compliant media run with the official story
    The media may have picked it up from RTE, who didn't have the medical background in detail. But the report itself pushes the issue of manners and sensitivity to the top.

    The manners angle is easier to understand maybe, although what part of "didn't read/ignored/switched off the heart monitor" is too hard to understand ?
    “ We cannot withdraw our cards from the game. Were we as silent and mute as stones, our very passivity would be an act. ”
    — Jean-Paul Sartre

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    Default Re: Portlaoise Maternity Service Report - It's About Avoidable Deaths, Not Bad Manners

    INMO on Primetime is saying it is staffing - the HSE says it was not - nobody wants to tackle to issue of bad medical practice.
    “ We cannot withdraw our cards from the game. Were we as silent and mute as stones, our very passivity would be an act. ”
    — Jean-Paul Sartre

  5. #5
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    Default Re: Portlaoise Maternity Service Report - It's About Avoidable Deaths, Not Bad Manners

    The Coombe, Portlaoise, The Report and Managing the Media

    http://nocountryforpregnantwomen.blo...aoise-the.html

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