Maternal death is no longer one of the specified serious adverse events under the remit of the HSE’s obstetric event support team (OEST).
In December 2022, the OEST Clinical Lead Dr Peter McKenna informed HSE Chief Clinical Officer Dr Colm Henry that maternal death was no longer within the scope of the OEST. According to an update report for Dr Henry, “upon review it seems to be unnecessary for the OEST to be notified when hospitals are already mandated to report maternal deaths to NWIHP [National Women and Infants Health Programme]”.
The NWIHP would be “fully engaged with hospitals” in the event of maternal death, according to another communication to Dr Henry when he raised questions on the matter. Dr Henry had noted that inclusion of maternal deaths “though small in number were a significant part of the OEST work”.
The OEST, which is part of the NWIHP, was established in August 2021 as a “support service” for hospitals following serious adverse events in obstetrics and to yield learning for national response.
“By engaging with the sites immediately following the occurrence of an adverse event the OEST can offer another set of eyes and make suggestions on areas of focus for the review…,” according to the HSE.
Minister for Health Stephen Donnelly has described the OEST as providing “objective oversight over a specified list of obstetric clinical incidents”.
A Department of Health spokesperson said: “Maternal death is not now a specified event, as this is under the remit of the NWIHP Clinical Director. The HSE advised the Department that this was in line with the main focus of the HSE’s OEST, which is improving term perinatal outcomes.”
The current list of specified incidents under the OEST remit are intrapartum foetal death, early neonatal death, and babies that require therapeutic hypothermia (the three categories apply to term babies with no life-limiting conditions).
Meanwhile, documents released through Freedom of Information law show that Dr Henry raised the possibility of amending service level agreements with the three Dublin maternity hospitals to require their cooperation with the OEST.
The Masters of the three voluntary hospitals wrote to Dr McKenna in April 2022 stating they already had well-established risk management and review systems. A “compromise” has since been agreed in regard to the Coombe Women and Infants University Hospital and National Maternity Hospital whereby the OEST can attend their maternity networks’ serious incident management fora.
However, while it is understood the Rotunda Hospital had also agreed to this arrangement, the RCSI Hospital Group has not yet permitted access to the forum as of late April 2023.