Blog: Another HSE report, but have lessons been learned?
Karen Kearney, medical negligence solicitor at Cantillons Solicitors in Cork, questions if the Government has learned lessons from a new report on perinatal deaths.
The HSE published its long awaited report, entitled The HSE Maternity Clinical Complaints Review, on Tuesday 23 May 2017.
Frankly, I have lost track of the number of reports that have come into being since Primetime Investigates first reported on the tragic deaths of a number of babies in the Midlands Regional Hospital Portlaoise on 30 January 2014. I think this latest report is the sixth such report.
The review, the subject matter of this latest report, was chaired by Dr Peter Boylan (former Master of Holles Street) and 153 maternity-related complaints were looked at, these complaints having been made on foot of the Primetime programme.
The complaints related to events spanning 40 years. The nature of the complaints were varied to include those related to perinatal deaths, management of labour, communications.
Arising out of the review, and on foot of recommendations made by the Clinical Review Team, the HSE has furnished letters of apology to 14 families, which is of course to be welcomed.
As a medical negligence solicitor with Cantillons Solicitors, my colleagues and I have read many HSE reports on adverse events involving our clients over the years.
One such client of mine was an elderly gentleman who was exposed to and contracted Hepatitis B in a HSE-run hospital in the southeast. Unbelievably, this hospital had engaged in a practice of using re-usable needle holding devices in the phlebotomy procedure (the practice of taking blood) up to 99 times! In this case, an investigation and look back review was carried out by the HSE and despite the fact that several draft reports issued (which this firm had to fight tooth and nail in the litigation process to get), and despite assurances that the final report would be published, it never saw the light of day and is no doubt languishing in some dark corner of an office gathering dust.
At least we have moved on from this practice of sweeping mistakes under the carpet - but we have not moved fast enough or indeed far enough, in my view.
There is no sign of anyone being held to account for what happened in the Midlands Regional Hospital, Portlaoise or indeed in any of the other eight hospitals that came under review in this report.
I note with interest that one of the recommendations contained within the report is that “Timely open disclosure to patients and families is mandatory in the event of a possible adverse experience”.
Recommendations are all well and good but it is time for action.
Following publication of this report, Health Minister Simon Harris has been quoted as saying: “The number of these complaints over such a long period of time is a wake-up call to all of us to ensure our health system becomes more open, and deploys systems that are responsive, and listen and learn from patients.”
Yet, as I pointed out in a previous blog, Mr Harris plans to introduce a voluntary open disclosure scheme which will give medical professionals legal protection for any information given following a patient safety incident. In other words, telling the truth will be optional and protected.
The HSE has had a National Open Disclosure Policy since November 2013. It is merely a policy, a guideline. My colleagues have seen it ignored time and time again.
Unless the truth is legislated for, and sanctions are imposed on those who don’t tell the truth, I am not optimistic that we have seen the last of tragic events such as those that occurred in Portlaoise hospital and other hospitals and indeed the last of these types of report.