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Lack of stakeholder feedback in perinatal death reports

Analysis of national inquiry reports relating to maternity services and adverse pregnancy outcomes has revealed feedback was sought from key stakeholders prior to publication in just 20 per cent of cases.

This is despite the fact that “involving key stakeholders in the making of recommendations increases the chance of successful implementation”, an article published recently in the IMJ found.  

Titled ‘Irish Inquiry Reports Relating to Perinatal Deaths and Pregnancy Loss Services’, the review examined 10 national inquiry reports published between 2005-2018.

It found that 90 per cent of reports advised enhancing adverse incident management in maternity services and 100 per cent of reports analysed included recommendations on increasing workforce staffing and/or training.

“A service that is chronically understaffed will not be able facilitate protected time for important training and education of its workforce,” said the report authors.  

“A clear timeline for implementation of all recommendations was set out in only one report.”

Furthermore, 30 per cent of reports highlighted a concern regarding the incomplete implementation of previous inquiry recommendations.

The analysis, carried by the Irish Centre for Maternal and Child Health Research (INFANT), National Perinatal Epidemiology Centre (NPEC) and University College Cork (UCC), also drew attention to the negative impact of lengthy inquiries.

“Generally, pregnancies are seen having only positive outcomes and therefore adverse outcomes can generate significant public interest. Inquiries take a significant time to be completed (7 months to three years in this cohort), this delay in report publication means that public opinion is often formed by immediate media coverage of events rather than inquiry findings.”

Limited staffing in hospitals already under growing pressure were other factors considered by the authors in relation to inquiries.

“Ireland is a small country with a limited number of experts/specialists in its maternity service; appointing experts to lengthy inquiry processes reduces their time commitment to a service already under pressure.”

Due to the nature of inquiries, the authors proposed that in some cases internal inquiries “might instead address local concerns in a more timely manner”.

“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,” the article concluded.

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