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Investigation Into the Safety, Quality and Standards of Services Provided

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Investigation Into the Safety, Quality and Standards of Services Provided Investigation into the safety, quality and standards of services provided by the Health Service Executive to patients, including pregnant women, at risk of clinical deterioration, including those provided in University Hospital Galway, and as reflected in the care and treatment provided to Savita Halappanavar 7 October 2013 Investigation into the safety, quality and standards of services provided by the Health Service Executive to patients, including pregnant women, at risk of clinical deterioration, including those provided in University Hospital Galway, and as reflected in the care and treatment provided to Savita Halappanavar Health Information and Quality Authority About the Health Information and Quality Authority The Health Information and Quality Authority (HIQA) is the independent Authority established to drive continuous improvement in Ireland’s health and personal social care services, monitor the safety and quality of these services and promote person-centred care for the benefit of the public. The Authority’s mandate to date extends across the quality and safety of the public, private (within its social care function) and voluntary sectors. Reporting to the Minister for Health and the Minister for Children and Youth Affairs, the Health Information and Quality Authority has statutory responsibility for: Setting Standards for Health and Social Services – Developing person-centred standards, based on evidence and best international practice, for those health and social care services in Ireland that by law are required to be regulated by the Authority. Social Services Inspectorate – Registering and inspecting residential centres for dependent people and inspecting children detention schools, foster care services and child protection services. Monitoring Healthcare Quality and Safety – Monitoring the quality and safety of health and personal social care services and investigating as necessary serious concerns about the health and welfare of people who use these services. Health Technology Assessment – Ensuring the best outcome for people who use our health services and best use of resources by evaluating the clinical and cost effectiveness of drugs, equipment, diagnostic techniques and health promotion activities. Health Information – Advising on the efficient and secure collection and sharing of health information, evaluating information resources and publishing information about the delivery and performance of Ireland’s health and social care services. 1 Investigation into the safety, quality and standards of services provided by the Health Service Executive to patients, including pregnant women, at risk of clinical deterioration, including those provided in University Hospital Galway, and as reflected in the care and treatment provided to Savita Halappanavar Health Information and Quality Authority Table of Contents About the Health Information and Quality Authority 1 Executive Summary 8 Recommendations 26 Part 1 – Introduction and Background, and Methodology 33 1. Introduction and Background 34 1.1 Background to the HIQA investigation 36 1.2 Establishment of the HIQA investigation 38 2. Methodology 41 2.1 Overall approach 41 2.2 Investigation Team 42 2.3 Advisory Panel 42 2.4 Lines of Enquiry 42 2.5 Patients’ and relatives’ experience 43 2.6 Investigation findings 43 2.7 Review of literature 44 2.8 Documentation and data 44 2.9 Interviews 44 2.10 Group meetings 45 2.11 Observation 45 2.12 Patient healthcare record review 45 2.13 Due process feedback 45 Part 2 – Profile of Galway and Roscommon University Hospitals Group 47 3. Galway and Roscommon University Hospitals Group including University Hospital Galway 48 3.1 Introduction 48 3.2 Profile of Galway and Roscommon University Hospitals Group 48 3.3 Profile of maternity services at University Hospital Galway 50 3 Investigation into the safety, quality and standards of services provided by the Health Service Executive to patients, including pregnant women, at risk of clinical deterioration, including those provided in University Hospital Galway, and as reflected in the care and treatment provided to Savita Halappanavar Health Information and Quality Authority Part 3 – Findings in relation to the care provided to Savita Halappanavar, other clinically deteriorating pregnant women (as reflected in the care and treatment of Savita Halappanavar), and other findings at University Hospital Galway 53 4. Findings in relation to the care provided to Savita Halappanavar and the quality of maternity services 54 4.1 Introduction 54 4.2 Pathway of care provided to Savita Halappanavar 55 4.3 Summary of findings in relation to the care provided to Savita Halappanavar and the quality of maternity services 65 5. Findings in relation to the clinically deteriorating pregnant patient, as reflected in the care and treatment provided to Savita Halappanavar 66 5.1 Introduction 66 5.2 Care of the clinically deteriorating pregnant patient 66 5.3 Monitoring to facilitate the early identification of a clinically deteriorating pregnant patient 67 5.4 Early intervention and escalation (including access to critical care) 68 5.5 Identification and management of maternal sepsis 69 5.6 Clinical handover 71 5.7 Summary of findings in relation to the clinically deteriorating pregnant patient, as reflected in the care and treatment provided to Savita Halappanavar 72 6. Findings in relation to the maternity services at University Hospital Galway 74 6.1 Access arrangements for any pregnant woman attending University Hospital Galway 74 6.2 Pathways and environment 74 6.3 Healthcare records management 78 6.4 Maternity Services Workforce – University Hospital Galway 80 6.5 Summary of findings in relation to maternity services at University Hospital Galway 89 7. Findings in relation to the clinically deteriorating general adult patient 91 7.1 Monitoring to facilitate early identification of clinical deterioration 91 7.2 National Early Warning Score implementation at University Hospital Galway 91 7.3 Early intervention and escalation (including access to critical care) 92 7.4 Identification and management of sepsis in general patients 93 7.5 Summary of findings in relation to the clinically deteriorating general adult patient 94 4 Investigation into the safety, quality and standards of services provided by the Health Service Executive to patients, including pregnant women, at risk of clinical deterioration, including those provided in University Hospital Galway, and as reflected in the care and treatment provided to Savita Halappanavar Health Information and Quality Authority Part 4 – Findings in relation to the Governance of Galway and Roscommon University Hospitals Group and University Hospital Galway 95 8. Governance of Galway and Roscommon University Hospitals Group and University Hospital Galway 96 8.1 Introduction 96 8.2 Galway and Roscommon University Hospitals Group corporate and clinical governance structure 96 8.3 Corporate governance arrangements 99 8.4 Governance arrangements for incident management and the implementation of recommendations of the investigations following the death of Savita Halappanavar 106 8.5 The Women’s and Children’s Directorate at University Hospital Galway 107 8.6 Summary of governance of Galway and Roscommon University Hospitals Group and University Hospital Galway 112 Part 5 – Profile and findings of Maternity Services Nationally 115 9. Profile and governance arrangements for maternity services nationally 116 9.1 Introduction 116 9.2 National governance and reporting arrangements for maternity services 116 9.3 Governance arrangements for public providers of maternity services 118 9.4 Activity data: public providers of maternity services 119 9.5 Summary of the findings in relation to profile and governance arrangements for maternity services nationally 123 10. Findings in relation to National Maternity Services 125 10.1 Introduction 125 10.2 Maternity services workforce 125 10.3 Maternity services staffing: international and national literature review and recommendations from investigations 127 10.4 Summary of findings in relation to National Maternity Services 132 11. Findings in relation to use of information 135 11.1 Introduction 135 11.2 Performance monitoring of maternity services 136 11.3 Summary of findings in relation to use of information 142 5 Investigation into the safety, quality and standards of services provided by the Health Service Executive to patients, including pregnant women, at risk of clinical deterioration, including those provided in University Hospital Galway, and as reflected in the care and treatment provided to Savita Halappanavar Health Information and Quality Authority Part 6 – Findings in relation to Antimicrobial surveillance 143 12. Antimicrobial surveillance 144 12.1 Introduction 144 12.2 Microbiology services 144 12.3 National alert systems 146 12.4 Summary of findings in relation to antimicrobial surveillance 147 Part 7 – Findings in relation to National Incident Management and Learning 149 13. Findings in relation to national incident management and learning 150 13.1 Introduction 150 13.2 National Systems for incident reporting 151 13.3 National governance structures for incident management and escalation 153 13.4 Improving incident management processes 153 13.5 Learning from a national patient safety inquiry 155 13.6 Implementation of HIQA reports 157 13.7 Learning from coroners’ recommendations 164 13.8 Learning from the service user 165 13.9 Learning from international evidence and best practice 165 13.10 Governance arrangements
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