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Dublin: 18 °C Friday 31 October, 2014

Minister writes to HSE over failure to implement Tania McCabe recommendations

A HIQA report into the death of Savita Halappanavar revealed that many of the recommendations issued after the death of Tania McCabe six years ago have not been implemented.

Image: Sam Boal/Photocall Ireland

THE HEALTH MINISTER has written to the HSE and Ireland’s healthcare watchdog to insist the recommendations issued following an investigation into the death of Tania McCabe six years ago are implemented.

James Reilly said he has contacted both the Director General of the HSE and the chairman of the board of HIQA in the wake of the report into the death of Savita Halappanavar which revealed that not all of the recommendations are adhered to nationally.

“I am determined that the recommendations of the HSE inquiry into the death of Tania McCabe and her infant son Zach at Our Lady of Lourdes Hospital in 2007, and the recently published HIQA Report of the care and treatment provided to Ms. Halappanavar, will be fully implemented and that any actions required will be implemented across our health services,” the Minister said in response to a parliamentary question from Billy Timmins.

He has asked the two bodies to monitor the progress of hospitals against the recommendations. He also gave them “further directions on how progress on the implementation of the recommendations should be monitored and reported”.

“The process for implementing recommendations will also address any outstanding issues arising from the HSE inquiry into the death of Tania McCabe and her infant son Zach,” added the Fine Gael TD.

I am determined that out of the sad loss of these young women our whole health system will learn lessons that will ensure that it provides safe, patient-centred care.

The HIQA investigation into the death of Savita Halappanavar last year found that very little had been learned from the tragic events to befall the McCabe family at Our Lady of Lourdes Hospital in Drogheda in 2007.

The similarities between the two cases was “probably one of the most disturbing findings” of the probe, the Director of Regulation Phelim Quinn told reporters during a press briefing.

As part of the investigation into the death of Savita Halappanavar, HIQA requested the HSE to provide details of how the recommendations of the report into the circumstances of the 2007 deaths had been implemented at each of the 19 public maternity units.

Of the 19, only five provided a details status update for all 27 recommendations of that report. They were the Midland Regional Hospital Mullingar, Coombe Women’s and Children’s Hospital, the Rotunda, Our Lady of Lourdes Drogheda and the Mid-Western Regional Maternity Hospital.

Of the remaining 14 – including University Hospital Galway – six reported their status against a different investigation or gave no comment. A number of the six reported that evidence for implementation was not in existence.

“This is unsatisfactory and concerning,” said the report.

One of the recommendations asked the HSE to adopt the international Surviving Sepsis Campaign to build awareness, encourage early recognition and standardise treatments.

The responses from hospitals across the country indicated a regionalised rather than national approach to the recommendations.

This lack of a coordinated approach raises a “fundamental and worrying deficit in our health system” again, said HIQA.

Namely the ability to implement and apply system-wide learning from adverse events across the system in a timely and appropriate manner in order to prevent the recurrence of patient safety events that may cause harm, or worse, to future patients.

Although HIQA does not have enforcement powers, Quinn said the 34 recommendations of the report into the treatment of Savita Halappanavar will have to be implemented satisfactorily, a sentiment echoed by Reilly.

In the wake of the report, the McCabe family said they were surprised and saddened to learn that Irish hospitals had not implemented recommendations that arose from a report into her death.

Read: Tania McCabe’s family shocked that HSE still behind on sepsis testing

‘An appalling indictment of State failure’: Consultant calls for more maternity staff

‘Disturbing similarities’ between Savita and Tania McCabe deaths

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