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Portiuncula Report - 'Serious errors in management'

Featured Portiuncula Report - 'Serious errors in management'




Last Thursday, the Saolta University Health Care Group published the report of the External Independent Clinical Review of Maternity Services at Portiuncula University Hospital (PUH).

  This review followed a preliminary review which was undertaken by the Saolta Group into the care provided to six women whose babies were referred from PUH for Therapeutic Hypothermia (head cooling) in 2014.

  An additional 12 cases involving 10 families relating to a number of different perinatal events at PUH dating from 2008 to 2014 were later added to the external review.

  A total of 18 cases, involving 16 families from 2008 to 2014, form part of the review published last week. 

  In their report, the Clinical Review Team state that of the 18 cases reviewed, serious errors in management occurred in ten cases that would have probably made a difference to the outcome for those babies. Of the 18 cases reviewed, six involved cases where the baby had died. In four of these cases there were significant failings in the care provided to those babies. The Clinical Review Team also identified contributory factors and/or incidental findings in each of the 18 cases reviewed.

  The review report highlighted a number of key issues relating to the service provided in PUH between 2008 and 2014. These include delays in escalation of concerns to more senior decision makers, deficits in staff numbers across both medical and nursing, poor CTG (trace) interpretation, and concerns relating to the administration of oxytocin during labour.

  The review report raised concerns around the way many families were communicated with during or after their time in hospital.

  The HSE said that since the concerns were identified in late 2014, the Saolta Group and PUH have put in place a significant number of measures to improve patient safety.



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