Irish inquiry reports relating to perinatal deaths and pregnancy loss services

Helps, Änne; Leitao, Sara; O'Byrne, L.; Greene, Richard A.; O'Donoghue, Keelin

Irish inquiry reports relating to perinatal deaths and pregnancy loss services

Files

Irish-Inquiry-Reports-Relating-to-Perinatal-Deaths-and-Pregnancy-Loss-Services-1.pdf(431.35 KB)

Published Version

Date

2020-02

Authors

Helps, Änne

Leitao, Sara

O'Byrne, L.

Greene, Richard A.

O'Donoghue, Keelin

Publisher

Irish Medical Organisation

Abstract

Aims: External inquiries are carried out following specific adverse events in healthcare, many in maternity care; to identify issues and make recommendations to improve standards of care. Methods: Ten publically-available national inquiry reports published between 2005-2018 relating to pregnancy loss services, were reviewed by 2 clinicians, separately, examining the content and recommendations from each report. Results: A total of 258 recommendations were made in 9 reports (90%). Five inquiries (50%) clearly stated that affected families were involved and four (40%) involved affected clinical staff. In 9 reports (90%) recommendations included: increase workforce staffing and/or training, strengthen clinical governance, enhance adverse incident management and comprehensive data collection e.g. maternity outcomes. Only two inquiry reports (20%) stated that feedback was sought from key stakeholders prior to publication. Conclusion: A collaborative and standardised inquiry process involving and supporting all persons affected as well as key stakeholders would ensure that all relevant issues are identified, recommendations are implemented and essential lessons are learned.

Keywords

External inquiries , Adverse events , Healthcare , Ireland , Maternity care

Citation

Helps, Ä., Leitao, S., O'Byrne, L., Greene, R. and O'Donoghue, K. (2020) 'Irish inquiry reports relating to perinatal deaths and pregnancy loss services', Irish Medical Journal, 113(2), P21 (7pp). Available at: http://www.imj.ie/wp-content/uploads/2020/02/Irish-Inquiry-Reports-Relating-to-Perinatal-Deaths-and-Pregnancy-Loss-Services-1.pdf (Accessed: 14 May 2020)