RCSI Hospitals will not permit the HSE obstetric event support team (OEST) to attend its maternity serious incident management forum (SIMF).
The OEST, which was established in August 2021, is part of the HSE National Women and Infants Health Programme (NWIHP).
The HSE has described the OEST as a “support service” for hospitals following serious adverse events in obstetrics with an aim of disseminating learning nationally. “The responsibility of carrying out the review and accountability remain with the hospital in line with HSE policies,” according to the NWIHP.
The OEST’s original remit encompassed four serious adverse events: Maternal death; intrapartum foetal death; early neonatal death; and babies requiring therapeutic hypothermia. The latter three categories apply to term babies with no life-limiting conditions.
In December 2022, the OEST Clinical Lead Dr Peter McKenna informed the HSE Chief Clinical Officer Dr Colm Henry that it had removed maternal death from its remit due to a replication of reporting requirements on hospitals.
A HSE spokesperson told the Medical Independent (MI): “The OEST has sought access to the RCSI Hospital Group SIMF, but this has not, as yet, been granted.”
“The issue has been escalated within the HSE and is following the appropriate governance line.”
As previously reported by MI, in April 2022 the Masters of the Dublin maternity hospitals questioned what “meaningful advantage” the OEST would bring to their “successfully functioning risk management and review systems”.
In summer 2022, the NWIHP and Masters reached a “compromise” such that the OEST could attend their Hospital Groups’ maternity SIMFs. This was different to the original OEST model which involved the team visiting sites following adverse events and expediting the sharing of learning nationally.
According to internal HSE communications obtained under Freedom of Information law, this “compromise” was suggested by the Rotunda’s Master at that time, Prof Fergal Malone. However, the Rotunda’s parent group – RCSI Hospitals – has continued to deny the OEST access to its maternity SIMF.
Last April, NWIHP Director Mr Kilian McGrane told MI there had been “multiple correspondences” to RCSI Hospitals on this matter but “to date, we haven’t found a way of getting through the impasse”.
When contacted for comment, RCSI Hospitals issued the same statement as it provided to MI in April 2023.
“RCSI Hospital Group welcomes OEST and looks forward to an opportunity to contribute to a broader discussion on their review approach and have fully cooperated with them to date on all information/review requests,” outlined the statement.
Meanwhile, the HSE stated that an external review of the OEST will be conducted as it has been operational for over two years.
“The OEST has been operational for over two years, it is therefore timely for NWIHP to consider the OEST experience to date, its processes and effectiveness and international developments in this area. An external review of OEST will take place, and may propose changes to the current approach.”
Funding of €540,000 was provided to support the establishment and expansion of the OEST across the maternity network from Budget 2022.
“The OEST programme team accounts for around €320,000 of the allocated funding. OEST operating expenses also include on-site attendance at various maternity hospitals when reviewing incidents, as well as hosting/facilitating learning events nationally,” according to the HSE.
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